STERILITY  AND 
CONCEPTION 


Schematic  Drawing  Showing  Different  Points  Where  Conception  Takes  Place. 

A.,    ovum.     B.,    spermatozoa,     i,    tubal    conception.     2,    uterine   conception. 
3,  ovarian  conception.     4,  abdominal  conception. 


STERILITY  AND 
CONCEPTION 


BY 

CHARLES  GARDNER  CHILD,  Jr.,  M.D. 

PROFESSOR  OF   aTNECOLOGY,   NEW  YORK  POLYCLINIC   MEDICAL 
SCHOOL  AND   hospital;     attending  GYNECOLOGIST,   CITY 

hospital;  consulting  gynecologist,  st.  Bartho- 
lomew's  HOSPITAL    and    NASSAU    HOSPITAL. 

fellow,   american    gynecological 
society;  new  york  obstet- 
rical SOCIETY,  ETC. 


GYNECOLOGICAL  AND  OBSTETRICAL  MONOGRAPHS 


D.   APPLETON  AND  COMPANY 

NEW  YORK  LONDON 

1922 


COPYRIGHT,    1922,  BT 

D.  APPLETON  AND  COMPANY 


PKIMTED  IN  THE  XmiTED  STATES  OE  AMSUCA 


1. 5" 


6' 


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L  '<> , 


PREFACE 

The  following  study  of  sterility  and  some  of  its  allied  conditions 
is  undertaken  in  the  hope  that  it  may  help  thoughtful  students  to 
attain  at  least  a  comprehensive  knowledge  of  this  most  important 
subject.  It  is  intended  as  much  for  the  general  practitioner,  to  whom 
these  cases  as  a  rule  first  apply,  as  for  the  specialist,  but  it  is  the  latter, 
however,  who  should  constitute  the  court  of  last  appeal  and  sit  in 
final  judgment  on  the  respective  merits  of  each  case. 

It  is  most  unfortunate  that  the  great  progress  of  theoretical  knowl- 
edge in  recent  times  has  not  always  been  accompanied  by  a  correspond- 
ing advancement  in  practical  interpretation  and  we  have,  therefore,  to 
admit  that  a  great  deal  of  what  is  to-day  called  "exact  science"  is 
still  very  far  from  being  such. 

The  vast  extension  of  medical  knowledge  in  the  past  fifty  years, 
which  has  been  made  possible  only  by  a  division  into  specialties,  has 
rendered  it  nigh  unto  impossible  for  one  mind  to  cover  the  whole  field 
of  medicine  with  equal  thoroughness.  My  own  command  of  the 
various  branches  of  medicine  is  uneven  and  defective  and,  even  were 
I  largely  endowed  with  the  artistic  faculty  of  comprehensive  presen- 
tation, I  should  still  be  unable  to  write  a  complete  treatise  on  sterility. 

To-day,  more  than  ever  before,  woman  is  called  upon  to  play  a 
most  exacting  role  in  life  and  one  in  which  the  question  of  mental 
capacity  has  assumed  a  very  great  proportion.  At  times  it  takes  such 
precedence  over  almost  everything  else,  even  to  the  extent  of  com- 
pletely overshadowing  all  consideration  of  her  physical  well-being, 
that  it  is  quite  possible  to  suppose  at  some  time  in  the  future,  should 
this  continue,  there  might  develop  a  race  of  women  who  would  be  such 
in  little  else  but  name.  This  could  only  be  brought  about,  however, 
at  the  expense  of  their  child-bearing  function  and,  if  they  should 
thus  refuse  to  breed,  or  succeed  in  making  breeding  a  physical  im- 
possibility, then  would  come  the  end  of  the  race. 

We  are  facing  at  the  present  time  in  the  United  States  a  higher 
rate  of  sterility  and  a  lower  rate  of  fertility  among  our  native-born 
women  than  is  any  other  civilized  nation ;  the  estimated  rate  of  sterility 


iviSr-^  oSO 


vi  PREFACE 

for  all  classes  being  between  twenty  and  twenty-five  per  cent,  while  the 
number  of  those  absolutely  sterile  is  about  twelve  per  cent. 

Accompanying  this  steady  increase  in  sterility,  there  has  also  been 
a  proportionate  decrease  in  fertility  in  almost  every  civilized  country 
in  which  records  are  available,  so  that  woman's  progressive  unfruit- 
fulness  is  really  a  question  of  world-wide  importance.  In  the  United 
States,  the  increase  in  sterility  and  the  decrease  in  fertility  has  de- 
veloped much  more  rapidly  than  in  most  other  countries.  While  it 
has  been  estimated  from  reliable  sources  that  the  rate  of  fertility  in 
the  United  States,  at  the  close  of  the  eighteenth  century,  was  five  chil- 
dren to  a  marriage,  no  such  favorable  conditions  exist  any  longer.  In 
one  century  our  rate  of  sterility  has  mounted  from  two  to  over  twenty 
per  cent,  making  us  the  least  fertile  of  the  civilized  countries,  speaking 
of  native-born  and  not  immigrant  classes.  Thus  we  present  the  truly 
appalling  condition  where  our  sterility  is  far  greater  and  our  fertility 
much  lower  than  any  time  in  the  history  of  the  nation. 

The  existence  of  such  a  condition  as  this  is  of  sufficient  serious- 
ness to  call  imperatively  for  a  remedy,  and  it  is  only  by  giving  the 
subject  the  serious  consideration  and  wide  publicity  which  it  deserves 
that  we  can  hope  to  bring  to  the  people  a  realizing  sense  of  the 
ominous  fact  that,  unless  they  wake  up,  they  will  be  called  upon  to  face 
race  extinction  in  the  comparatively  near  future. 

In  the  present  monograph,  I  have,  with  full  realization  of  its 
many  shortcomings,  given  an  exposition  of  the  problem  with  the  en- 
deavor to  help  in  the  treatment  of  this  growing  social  blight  so  vitally 
concerned  with  the  welfare  and  survival  of  the  race. 

Charles  G.  Child^  Jr. 
New  York  Cmr 


CONTENTS 

CHAPTER  PAGE 

I.    Marital    Unfruitfulness i 

Modern  civilization  and  birth  control,  3 — Reproductivity  and  the 
educated  classes,  3 — Sterility  among  the  native  born,  5 — Sterility 
in  the  middle  classes,  7 — Eugenics  and  birth  control,  8 — Family 
decrease,  9 — Creative  and  developmental  differences  of  sex,  10 — 
Decay  of  parental  supervision,  12 — Decrease  in  marriages,  12 — 
Idealization  of  motherhood,  12 — Organized  voluntary  parenthood 
and  birth  control  societies,  13 — The  era  of  the  child,  14 — Home 
life,  14. 

II.     Origin  of  Life 16 

Harvey's  aphorism,  "Omne  vivum  ex  ovo,"  16 — Weismann's  theory 
of  germ  plasm,  16 — Theories  of  preformation,  17 — Fission,  17 
— The  ovum,  18 — Microscopy  of  the  germ  cells,  18 — Schulte's 
definition  of  the  cell,  20. 

III.  Development  of  the  Female  Cell 21 

The  ovaries,  21 — The  corpus  luteum,  21 — Endocrine  function  of 
corpus  luteum,  21 — Dual  function  of  the  ovary,  21 — The  so-called 
corpus  luteum  of  pregnancy,  23— Case  report,  23 — Ovulation, 
24 — Potential  immortality  of  protozoa,  24 — Ovulation  in  its  re- 
lation to  fertilization,  25. 

IV.  Method  of   Reproduction 28 

Protozoal  methods  of  reproduction,  28 — Formation  of  the  zyote, 
29 — Morphological  and  physiological  differences  between  the  ova 
and  spermatozoa,  29 — mitototic  cell  division,  30 — Early  ideas  of 
fertilization,  31 — The  span  of  life  of  a  spermatozoon,  31 — Definite 
sexual  attraction,  31 — Union  between  germ  cells,  32. 

V.    Growth  of  the  Fertilized  Cell 33 

The  imbedding  of  the  ovum,  23 — Survival  of  the  fittest,  35 — 
Seasonal  influence  and  breeding,  37 — Menstruation  and  Peri- 
odicity, 37. 

VI.    Definition  and  Classification 39 

Definition  of  fertility,  39 — Race  and  fertility,  39 — Definition  of 
sterility,  39— Sterility  classified,  39 — Case  report  on  sterility,  41 
— Predisposing  factors  of  sterility,  41. 

VII.    Etiology  43 

Pathological  conditions  influencing  sterility,  43 — Germ  cell  retarda- 
tion and  racial  poisons,  43 — Primitive  woman's  freedom  from 
sterility,  43— Etiology  and  sterility,  44— Anatomical  errors  and 
maldevelopment,  44 — Vaginismus,  44 — Dyspareunia,  44 — Case  re- 
port of  infantile  pelvis,  45 — Suspension  of  ovarian  activity,  46 — 
Menstrual  cessation  through  shock,  obesity,  climatic  changes, 
overindulgence  in  sexual  intercourse,  and  X-ray  exposure,  47 — 


viii  CONTENTS 


Acquired  sterility,  absolute  or  relative,  48 — Germ  cell  injury 
through  parental  alcoholism,  53 — Social  factors  and  reproductiv- 
ity,  54 — Frequent  child  bearing  and  reproductivity,  54 — Incom- 
patibility as  a  factor  in  sterility,  55. 

VIII.    Etiology — Diagnosis — Treatment 57 

Unfruitful  marriages,  57 — Quality  of  spermatozoa,  57 — Vitality, 
number,  and  motility  of  the  spermatozoa,  58 — Diagnostic  im- 
portance of  vaginal  and  cervical  smears,  58— Uterine  displace- 
ments, 59 — Study  and  examination  of  the  male  partner,  64 — 
Imperfect  sexual  relations,  65 — Study  and  examination  of  the 
female  partner,  66 — Rectal  examination  in  stout  subjects,  67 
— Postcoital  tests  for  sterility,  68 — Determining  the  patency  of  the 
fallopian  tubes,  69 — No  infallible  test  of  sterility,  y2 — Treatment 
of  sterility,  72 — Hygienic  measures,  73. 

IX.    Gonorrhea  and  Syphilis        . 75 

Venereal  disease  and  sterility,  75 — Gonorrhea,  75 — Statistics  of 
the  gonorrheal  menace,  79 — Case  report  of  gonorrheal  salpin- 
gitis, 80— Syphilis,  81. 

X.    Vaginismus  and  Dyspareunla. 92 

Case  report  of  vaginismus,  82 — Operative  relief  of  vaginismus,  83 
— Elxtreme  type  of  vaginismus,  83 — Dyspareunia  and  inflammn- 
tory  disease,  83 — Kraurosis  vulva,  85 — Urethral  caruncle  and  va- 
ginal cysts,  85 — Case  report  of  dyspareunia  due  to  vaginal  cyst, 
85 — Treatment  of  dyspareunia,  86. 

XI.    Pinhole  Os 87 

Not  always  a  cause  of  sterility,  87 — Frequently  blocked  by  mucus, 
87 — Case  report,  87. 

XII.  Chronic  Cervicitis .89 

Case  reports,  90 — Treatment,  90 — Medical,  90 — Operative  relief, 
91 — Congenital  erosion  of  the  cervix,  91. 

XIII.  Laceration  of  the  Cervix 82 

Case  report,  92 — Conditional  sterility,  >93 — Gravity  theory,  94 — 
Case  reports,  94 — Relative  sterility,  and  habitual  abortion,  95. 

XIV.  Anteflexion  of  the  Uterus -97 

Multilating  operations  of  no  value,  98 — Intra-uterine  stems  a  per- 
nicious practice,  98 — Proper  development  of  uterus,  98 — Exam- 
ination and  treatment  under  anesthesia,  99 — Cervical  stenosis 
and  faulty  surgery,   100. 

XV.    Retrodisplacements  of  the  Uterus loi 

Anatomy  of  the  uterus  and  adnexa,  loi — Ligamentous  attachments 
of  uterus,  103 — Mechanism  of  displacements,  106 — Pelvic  dia- 
phragm, 106 — Gravity  and  position  of  the  uterus,  109 — Arrested 

,  uterine  development,  109 — Classification  of  retrodisplacements, 
110— Case  reports,  114 — Habitual  abortion  due  to  congenital  re- 
trodisplacements of  uterus,  115 — Case  reports,  115 — Postpartum 
retrodisplacements,  116-— Case  reports,  116 — Operative  correction 
of  retrodisplacements,  117 — Treatment  of  retrodisplacements, 
117 — The  use  of  the  pessary,  119. 


CONTENTS 


IX 


CHAPTER  i-Aoa 

XVI.    Ovarian  Sterility '.      ...    122 

Gross  and  histological  description  of  nonovulating  ovary,  122 — Case 
reports,  124 — Ovarian  disease,  125 — Operative  treatment  of 
ovarian  sterility,  125 — Ovarian  decapsulation,  125. 

XVII.    Fibroid  Sterility 126 

Fibroids,  126 — Relation  of  fibroids  to  sterility  and  fertility,  127 — 
Case  history,  128 — Uterine  myomata,  129 — Case  histories,  129 — 
Myomectomy,  132. 

XVIII.    Subinvolution  and  Superinvolution 134 

Subinvolution,  causal  factors,  134 — Symptomatology,  134 — Case 
reports,  135 — Treatment,  135 — Superinvolution,  136 — Puerperal 
atrophy,  136 — Causal  factors,  136— Symptomatology,  136 — Diag- 
nosis, 136— Case  reports,  136. 


XIX.    Tubal  Occlusion 


Etiology,  138 — Route  of  infection,  138 — Catarrhal  conditions,  139 
— Case  reports,  140 — Gonorrheal  sterility,  139 — Acute  infections, 
142 — Trauma,  142 — ^^Case  report,  142 — Cases  of  doubtful  eti- 
ology, 143. 


XX. 


Contraceptives 

General  remarks  in  regard  to  birth  control,  146. 


138 


146 


XXI.    Abortion,  Premature  Birth,  and  Feticide 153 

Legal  definition  of  abortion,  153 — Criminal  abortion,  154 — Rela- 
tive frequency  of  interrupted  pregnancy,  155 — Hospital  statistics 
of  antenatal  death,  156 — Toxemias  of  pregnancy,  156 — Prema- 
turity, 157 — Infections,  158 — Gonorrhea,  158 — Hemorrhage,  158 
Percentage  of  prematurity,  158 — Case  report,  159 — Accidents 
of  childbirth,  160. 

XXII.    Pessary  Treatments  of  Retrodisplacements 161 

Postpartum  retrodisplacements,  161 — Technic,  163 — Types  of  pes- 
sary, 166 — Function  of  pessary,  168. 

XXIII.  Operative  Technic 169 

Enlarging  the  introitus  vaginalis,  169 — Dilatation  of  the  cervix, 
169— Curettage,  173 — Enlarging  the  external  os,  173 — Cervical 
repair,  174 — Lengthening  of  the  anterior  vaginal  wall  and  utero- 
vesical  ligament,  179 — Abdominal  incision,  181 — Advantages  of 
abdominal  incision,  184 — Retrodisplacement,  190 — Surgical  meas- 
ures, 191 — Myomectomy,  194 — Operation  for  tubal  occlusion,  197. 

XXIV.  Therapeutic  Abortion  and  Sterilization 199 

Therapeutic  abortion,  199 — Therapeutic  sterilization,  199 — Case 
history,  202. 


XXV.    Combined  Therapeutic  Abortion  and  Sterilization 

Case  histories,  206 — Operative  technic,  208 — Conclusions,  209. 


204 


ILLUSTRATIONS 

FIGURE  PACK 

Schematic    drawing    showing    different  .  points    where    conception    takes 
place Frontispiece 

1.  Formation  of  polar  body  (Sobotta)  X500 16 

2.  Formation  of    female  pronucleus  and   its    fusion  with  male  pronucleus 

(Sobotta)    X500 17 

3.  Changes  in  the  segmented  nucleus    (Sobotta)    X500 18 

4.  Formation   of   mulberry   mass    (Sobotta)    XSCX) 19 

5.  Diagram  of  holoblastic  ovum  and  a  meroblastic  ovum 22 

6.  First  stages  of  segmentation  of  mammalian  ovum 22 

7.  Ovarium  ovum  of  a  mammifer 26 

8.  Ovum  of  the  cat ;  highly  magnified.     Semi-diagrammatic     ....  29 

9.  Ovum  of  rabbit  from  the  fallopian  tube,  twelve  hours  after  impregnation  31 

10.  Fertilization  of  the  ovum  of  an  echinoderm 33 

11.  Human  spermatozoa 35 

12.  Infantile  uterus 45 

13.  Bier  cup  in  place  over  cervix 90 

14.  Anteflexion  of  the  uterus 99 

15.  Normal   position   of   uterus 102 

16.  Retroflexion  of  the  uterus 104 

17.  Schematic  representation  of  varieties  of  fibroids 127 

18.  Author's  uterine  repositor 162 

19.  Manual  replacement  of  retroflexed  uterus 164 

20.  Smith   retroflexion  pessary 165 

21.  Introduction  of  pessary;  first  step 167 

22.  Introduction  of  pessary;  second  step .  167 

23.  Pessary  in  place 168 

24.  Enlarging  introitus 169 

25.  Henrotin's   traction   forceps 170 

26.  Martin's  uterine  sound 170 

27.  Introduction  of  the  uterine  sound  in  stenosis  of  the  internal  os    ,       .       .  171 

28.  Cervical  dilators 172 

29.  Operation  for  pinhole  os,  enlarging  the  external  os 174 

30.  Cervical    repair 175 

31.  Cervical  repair — Sutures  tied 176 

32.  Cervical  amputation.    First  step,  cervix  drawn  down  and  circular  incision 

made  separating  the  vagina  at  its  point  of  contact 177 

xi 


xii  ILLUSTRATIONS 

FIGURE  PAGE 

33.  Cervical   amputation.     Second   step 178 

34.  Cervical  amputation  completed.     Sutures  introduced  and  ready  to  tie     .  179 

35.  Lengthening  of  the  anterior  vaginal  wall  and  uterovesical  ligament  .       .  180 

36.  Author's  transverse  suprapubic  abdominal  incision 183 

37.  Transverse  suprapubic  abdominal  incision 185 

38.  Author's  tubal  and  intestinal  forceps,  with  rubber  jaws     .       .       .       ,  187 

39.  Author's   self -retaining  abdominal   retractor 188 

40.  Author's  travel  retractor *    ,  188 

41.  Closure  of  abdominal  incision;  author's  method 189 

42.  Transverse  suprapubic  abdominal  incision  two  weeks  after  operation       .  190 

43.  Round  ligament   shortening 193 

44.  Method  of  probing  the  tube     .       .       . 198 

45.  Therapeutic  sterilization;  author's  tubal  closure      .       .       .       .       .       .  203 

46.  Jackson's  tenaculum  forceps 205 

47.  Decidual  abortion 205 

48.  Author's  simultaneous  abdominal  abortion  and  sterilization  showing  in- 

cision through  abdominal  wall  and  fundus  of  the  uterus     .       .       .  207 

49.  Author's   simultaneous  abdominal  abortion   and   sterilization      .       ,       .  208 

50.  Author's  simultaneous  abdominal  abortion  and  sterilization    .       ,       .       .  200 


STERILITY  AND 
CONCEPTION 


STERILITY  AND  CONCEPTION 


CHAPTER  I 

STERILITY  AND  FERTILITY  CONSIDERED  FROM  THE  ECONOMICAL, 
SOCIAL.  AND  ETHICAL  SIDE 

MARITAL    UNFRUITFULNESS 

Modern  civilization  and  birth  control — Reproductivity  and  the  educated  classes — 
Sterility  among  the  native  born — Sterility  in  the  middle  classes — Eugenics  and 
birth  control — Family  decrease — Creative  and  developmental  differences  of  sex 
— Decay  of  parental  supervision — Decrease  in  marriages — Idealization  of 
motherhood — Organized  voluntary  parenthood  and  birth  control  societies — The 
coming  of  the  era  of  the  child — Development  of  home  life. 

Marital  unfruitfulness  has  always  been  considered  by  a  majority 
of  the  world's  people  as  a  great  misfortune,  and  in  ancient  times  even 
as  a  curse.  Upon  the  unhappy  woman  was  usually  placed  the  blame, 
although  it  was  generally  believed  that  her  fruitfulness  or  unfruit- 
fulness depended  upon  the  will  of  God.  Among  most  people  of  the 
earth  to-day,  children  are  considered  as  a  blessing  much  to  be  desired 
and  fertility  the  greatest  of  matrimonial  luck.  It  is  only  by  a  com- 
paratively few  that  fertility  is  not  held  in  the  highest  esteem,  and  these 
profess  to  hold  great  fruitfulness  as  contemptible  and  to  be  relegated 
to  the  animal  kingdom. 

A  fruitless  union  is  one  of  Nature's  saddest  tragedies.  From 
whatever  point  of  view  it  be  considered,  the  result  is  detrimental  to 
the  best  interests  of  society.  Granted  that  occasional  exceptions  to 
the  rule  may  be  encountered,  they  are  few  and  far  between,  and  are 
usually  dependent  on  chronic  disease  of  one  or  both  parties  that  only 
too  often  was  prenuptial  and  should  have  prohibited  union  in  the 
beginning.  Seldom,  if  ever,  is  a  childless  marriage  a  happy  one,  and 
only  too  often  the  sterility  becomes  a  disruptive  factor  destroying  the 
very  integrity  of  the  household.  The  man  with  his  many  outside 
interests  is  better  able  to  stand  the  monotony  of  a  childless  home  dur- 
ing the  comparatively  few  hours  he  spends  within  it  than  is  the 


2  STERILITY  AND  CONCEPTION 

woman.  She,  be  she  worthy  of  the  name,  has  of  necessity,  if  not 
from  actual  desire,  to  spend  a  greater  part  of  her  time  in  domestic 
duties  and  has  no  such  daily  outside  diversions  as  has  the  man. 

Nature  in  her  infinite  wisdom  has  provided  every  woman  from 
the  time  of  her  birth  with  a  maternal  sense  and  desire  for  children. 
This  is  satisfied  during  her  childhood  by  countless  dolls  upon  which 
she  lavishes  untold  care  and  affection,  even  into  advanced  puberty, 
but  as  maturity  is  reached,  these  no  longer  satisfy  the  woman  and  the 
longing  for  real  motherhood  asserts  itself.  If  this  natural,  maternal 
longing  is  not  gratified,  her  very  nature  will  frequently  become 
changed  and  her  mind  take  various  abnormal  slants  that  are  hardly 
conducive  to  her  happiness,  or  to  the  happiness  of  those  around  her. 

As  woman  possesses  certain  organs,  and  plays  a  part  in  life 
peculiarly  her  own,  we  should  naturally  expect  to  find  her  subject  to 
certain  diseased  conditions  more  or  less  dependent  on  her  anatomy, 
physiology,  and  mode  of  life.  These  I  shall  later  sum  up,  for  the  pur- 
pose of  brevity,  under  civilization  with  its  attendant  evils,  and  child- 
birth. 

In  our  present  highly  organized,  or  disorganized  state  of  society, 
incapability  of  reproduction  has  become  of  such  common  occurrence 
as  almost  to  lead  one  to  believe  that  it  is  a  necessary  evil  of  our  higher 
civilization.  The  very  social  life,  the  mental  and  physical  training  of 
our  young  girls  at  the  present  day,  especially  those  brought  up  in 
cities,  are  hardly  calculated  to  develop  later  on  a  high  degree  of 
fertility,  bui  we  are  fast  becoming  a  nation  of  cities,  and  must  face 
the  inevitable.  The  U.  S.  Census  Bureau  Report  for  1920  gives  the 
urban  population  as  51.4  per  cent  of  the  total  population  of  the  coun- 
try. Our  future  civilization  is  bound  to  be  urban,  and  the  problem 
of  an  increasing  rate  of  sterility  must  be  met  and  remedied;  other- 
wise we  shall  perish  from  the  land. 

In  early  times  the  people  gathered  chiefly  in  cities  for  temporary 
reasons.  They  sought  protection  from  marauders,  which  the  walled 
town  afforded,  going  out  each  day  into  the  surrounding  fields  to  work. 
City  life  was  then  a  necessity,  sought  only  for  mutual  protection  at 
night.  During  the  day  the  work  was  out  in  the  open  and  all  had  an 
equal  opportunity  for  healthy,  outdoor  exercise.  How  different  is 
the  condition  to-day ! 

In  a  more  or  less  ideal  state  of  society,  mating  would  take  place 
early  in  adult  life  and  it  would  be  the  desire  of  the  parents  that  their 
children  should  marry  early  and  produce  in  their  turn  many  healthy 


STERILITY  AND  FERTILITY  3 

children  to  be  brought  up  as  useful  citizens.  We  are,  however,  deal- 
ing not  with  the  ideal  but  ^yith  a  society  cursed  by  many  man-made 
social  conditions  which  make  early  marriage  at  the  natural  age  impos- 
sible for  most  young  people.  As  a  result  of  this,  irregular  unions 
occur  and  conditions  of  life  develop  which  lead  only  too  often  to 
immorality  and  to  prostitution.  All  of  these  unnatural  social  restric- 
tions impose  a  limit  upon  the  perfect  freedom  which  exists  in  the 
primal  marriage. 

To-day  urban  life  is  permanent,  and  the  city  is  sought  for  its 
attractions;  greater  human  intercourse,  multiplied  conveniences, 
superior  educational  advantages,  amusement,  excitement  and  endless 
variety  of  happenings,  all  of  which  appeal  only  too  strongly  to  the 
average  human  being,  while  the  dominant  influence  with  many  is  the 
great  opportunity  to  make  money,  or  what  is  probably  equally  as  bad, 
to  spend  it.  The  natural  trend  of  all  this  is  to  produce  congestion, 
misery,  and  selfishness ;  to  substitute  an  unnatural,  unhealthy  mode  of 
life  for  a  natural,  healthy  one  such  as  Nature  intended  her  children 
to  live.  The  old  gospel  of  "Be  fruitful;  multiply,  and  replenish  the 
earth"  has  been  superseded  by  a  modern  creed  of  "Practice  birth- 
control  and  enjoy  yourself." 

Modern  Civilization  and  Birth  Control. — The  rapid  growth  of 
modern  civilization  has  given  birth  to  many  marvels,  some  good  and 
some  bad.  Undoubtedly  one  of  its  saddest  spectacles  is  the  unprece- 
dented and  disproportionate  development  of  materialism  with  all  of 
its  consequent  demoralizing  effects  upon  the  individual. 

If  the  child  grows  in  body,  but  not  in  mind,  it  becomes  an  idiot. 
If  it  develops  physically  and  mentally,  but  not  morally,  it  becomes  a 
criminal.  If  the  woman  develops  physically  so  that  she  is  capable  of 
reproduction,  yet  with  a  moral  growth  so  stunted  that  she  refuses 
under  proper  conditions  to  undertake  the  cares  and  responsibilities  of 
motherhood,  she  is  a  criminal  against  society  and  a  drag  on  the  nation. 
The  comparatively  recent  athletic  tendency  among  women  is  admirable 
and  has  resulted  in  much  good  to  her  sex  from  a  physical  standpoint, 
but  we  should  remember  that  it  is  often  possible  to  develop  the  lower 
life  at  the  expense  of  the  higher.  The  golf  or  tennis  champion,  as  an 
animal,  may  be  admirable;  as  a  woman,  she  is  often  monstrous. 

Reproductivity  and  the  Educated  Classes. — The  higher  educa- 
tion of  women  has  marked  inhibitory  effects  upon  their  reproductivity, 
and  the  proportion  of  female  college  graduates  who  marry  is  less  than 
fifty  per  cent.    Our  young  girls  are  sent  early  to  school  and  subjected 


4  STERILITY   AND   CONCEPTION 

daily  to  long  hours  of  study,  often  in  badly  ventilated  classrooms,  for 
nine  months  in  the  year,  and  this  at  the  time  of  puberty,  one  of  the 
most  important  periods  of  their  life,  when  they  need  the  greatest  out- 
door freedom  and  exercise.  Later  comes  the  high  school  and  college 
with  their  increased  mental  strain  and  competition,  and  finally  mar- 
riage, when  only  too  often  she  is  hardly  more  than  a  mental  and 
physical  wreck.  Surely  as  Goodell  has  said,  ''If  woman  is  to  be  thus 
stunted  and  deformed  to  meet  the  ambitious  intellectual  demands  of 
the  day;  if  her  health  must  be  sacrificed  upon  the  altar  of  her  educa- 
tion, the  time  may  come  when,  to  renew  the  worn-out  stock  of  this 
Republic,  it  will  be  necessary  for  our  young  men  to  make  matrimonial 
excursions  into  lands  where  educational  theories  are  unknown." 

Even  a  most  casual  glance  into  the  system  of  education  of  our 
women  of  to-day  cannot  but  disclose  that  there  is  something  radically 
wrong  with  its  teachings,  and  that  we  are  far  from  solving,  or  even 
beginning  to  solve,  the  question  of  how  properly  to  educate  our  women. 
Co-education  has  a  great  deal  in  its  favor  and  is  worthy  of  a  more 
extended  trial,  for  the  intense  asceticism  of  our  present  educational 
system  is  accompanied  by  a  great  deal  that  is  bad.  While  it  may  be 
necessary  to  some  extent  for  the  woman  to  keep  pace  with  the  every- 
day social  demands  which  civilization  has  thrown  upon  her,  it  is  hardly 
calculated  to  bring  about  a  calm,  peaceful  poise  so  necessary  to  enable 
her  to  carry  out  to  best  advantage  the  demands  made  upon  her  woman- 
hood. 

So  much  is  heard  to-day  of  "woman's  sphere,"  "her  place  in  the 
world,"  and  her  "career,"  that  it  is  interesting  in  this  connection  to 
stop  and  seriously  consider  what  careers  are  really  open  to  her.  On 
first  sight,  the  field  would  appear  to  be  very  limited.  She  may  take 
up  writing  and  become  an  authoress  or  she  may  decide  upon  a  teaching 
career  in  either  school,  college,  or  the  arts.  Again,  she  may  enter 
politics.  These  are  all  worthy  pursuits  and,  when  conscientiously  car- 
ried out,  may  lead  to  gratifying  results. 

But  if  her  brain  is  developed  at  the  expense  of  her  body,  and  her 
studies  take  up  the  time  that  should  be  given  to  exercise  or  repose,  and 
if  we  add  to  this  a  strong  ambition  to  rival  or  excel  her  male  com- 
panions, the  result  is  apt  to  be  disastrous.  With  her  energy  bent  upon 
mastering  mathematics  or  the  classics ;  with  her  spare  moments  devoted 
to  collateral  reading;  with  her  out-of-door  life  and  exercise  entirely 
neglected;  it  is  not  surprising  that  her  physical  system  often  breaks 
under  the  strain.     The  pernicious  regime  begun  at  school  is  carried 


STERILITY  AND  FERTILITY  5 

through  into  college  life  with  even  more  disastrous  results.  Finally, 
graduating  with  high  honors,  often  a  recognized  authority  in  some 
particular  line  of  research,  she  is  but  a  physical  wreck. 

Then  comes  a  period,  often  of  even  higher  mental  pressure,  until 
she  marries.  The  married  life  is  usually  a  sterile  one,  either  from 
acquired  or  self-imposed  conditions.  It  is  among  college  graduates 
that  the  highest  percentage  of  sterility,  twenty-five  to  thirty  per  cent, 
exists  to-day. 

A  social  career,  although  widely  different,  is  yet  attended  by  evils 
almost  as  great  as  that  of  higher  education.  There  is  nothing  that  so 
unfits  a  woman  and  makes  her  so  discontented  with  her  own  home  and 
surroundings,  as  the  continual  whirl  and  excitement  with  which  society 
supplies  her.  The  constant  round  of  festivities  day  and  night  is  a 
strain  which  few  women  can  stand  for  any  length  of  time  without 
breaking  down.  Late  hours  night  after  night,  overeating,  overdrink- 
ing, with  a  freedom  of  intercourse  between  sexes  not  always  gratified 
by  legitimate  congress,  bring  about  a  rapid  moral  and  physical  degen- 
eration that  is  little  less  than  appalling. 

The  state  is  far  from  fulfilling  its  obligations  to  the  parents,  and 
especially  to  the  mothers.  Every  effort  should  be  made  to  give  her, 
during  her  pregnancy,  in  child-bearing,  and  child-rearing,  the  neces- 
sary physical,  moral,  and  medical  help;  for  upon  such  help  depends, 
to  a  great  extent,  the  future  well-being  of  our  land. 

Sterility  among  Native  Born. — Immediate  steps  must  be 
taken  in  the  interest  of  self-preservation;  for  with  a  high  and  increas- 
ing rate  of  sterility  among  our  native-born,  and  a  birth  rate  only  kept 
up  by  the  immigration  of  more  fertile  races,  the  United  States  faces 
a  great  crisis  to-day.  Among  our  native-born,  sterility  is  increasing 
and  fertility  decreasing;  there  is  an  ever-growing  desire  to  avoid 
parenthood;  and  we  are  being  outbred  by  the  immigrant  races. 
Restriction  of  immigration,  intelligent  governmental  help  to  parents, 
reduction  in  the  preposterously  high  cost  of  living  must  soon  be  accom- 
plished facts  if  a  truly  American  race  is  to  survive,  for  to-day  the 
native  born  American  belongs  to  a  vanishing  race. 

Nothing  has  as  yet  been  effectively  done  by  legislation  to  lighten 
the  burden  of  large  families.  The  meager  allowance  made  by  the 
State  to  the  income-tax-paying  class,  of  two  hundred  dollars  deduction 
for  each  child,  is  totally  inadequate,  and  a  liberal  endowment  of 
motherhood  in  all  classes  is  urgently  needed.  The  taxation  of  unmar- 
ried adults  has  much  to  be  said  in  its  favor,  and  a  great  deal  could  be 


^  STERILITY  AND   CONCEPTION 

done  by  a  wise  Government  towards  relieving  the  financial  burdens  of 
fathers  and  mothers  of  families,  especially  in  their  early  stages.  Every 
help  should  be  given  to  women  in  the  performance  of  those  duties 
which  are  their  natural  inheritance. 

A  study  of  the  abnormal  conditions  of  modern  life  will  show  many 
evils  responsible  for  the  increase  in  sterility,  and  just  where  the  remedy 
is  to  come  from,  it  is  even  difficult  to  surmise,  but  the  desertion  of  the 
land  for  the  cities,  so  steadily  progressive  almost  from  time  immemo- 
rial, would  seem  to  indicate  that  it  is  in  the  cities  that  the  race  will 
eventually  perish. 

Modern  materialism  is  preeminently  the  peril  of  the  American 
family,  for  it  leads  among  all  classes  to  a  restriction  in  the  size  of  the 
family.  This  growing  materialism  must  be  met  and  fought  at  every 
turn.  It  has  so  conquered  the  life  of  the  city  that  the  hope  of  the 
future  lies  in  the  country  and  suburban  districts.  As  the  cities  grow 
more  populous,  the  people  are  packed  into  closer  quarters,  herding 
together  in  hotels  and  tenements  to  the  marked  detriment  of  the  home 
life.  Among  the  rich,  hotel  and  club  life  has  all  but  displaced  the 
home  life,  while  among  the  poor,  rent  increase  has  forced  them  into 
such  cramped  quarters  that  home  life  is  out  of  the  question.  As  Henry 
George  has  said,  "The  proportion  of  births  is  notoriously  greater  in 
new  settlements,  where  the  struggle  with  Nature  leaves  little  oppor- 
tunity for  intellectual  life,  and  among  the  poverty-bound  classes  of 
older  countries,  who  in  the  midst  of  wealth  are  deprived  of  all  its 
advantages  and  reduced  to  all  but  an  animal  existence,  than  it  is 
among  the  classes  to  whom  the  increase  of  wealth  has  brought  inde- 
pendence, leisure,  comfort  and  a  fuller  and  more  varied  life."  This 
fact  was  long  ago  recognized  in  the  homely  adage,  "A  rich  man  for 
luck,  and  a  poor  man  for  children." 

All  possible  eifort  should  be  made  to  help  the  working  class, 
especially  the  better  educated,  who  have  a  real  interest  in  the  future 
of  the  country,  but,  where  living  on  meager,  fixed  incomes,  their  actual 
economic  position  is  below  that  of  the  lower  working  class,  even  that 
of  the  manual  laborer.  The  State  should  look  upon  every  potential 
parent  as  a  real  and  valuable  national  asset. 

In  the  days  of  large  families  there  was  a  wide  margin  to  allow  for 
accidents,  so  that  careful  nursing  was  of  minor  importance ;  but  while 
economical  reproduction  with  an  increase  in  parental  care  is  of  the 
greatest  importance,  probably  a  greater  asset  to  a  race  than  a  high  rate 
of  fertility,  it  should  not  be  carried  beyond  a  point  where  the  reduction 


STERILITY  AND  FERTILITY  7 

in  the  number  of  offspring  is  not  fully  compensated  for  by  the  cor- 
related reduction  of  infant  mortality.  If  we  infer  from  analogy,  then 
what  has  probably  occurred  in  the  process  of  evolution  is,  that  the 
advance  made  in  the  social  scale  has  been  associated  with  a  very 
marked  reduction  in  reproductivity. 

Man  and  higher  vertebrates  are  on  a  constantly  increasing  scale  of 
economized  reproduction  and  elaborated  parental  care.  Herbert 
Spencer,  in  his  "Principles  of  Biology,"  reached  the  conclusion  that 
genesis  decreases  as  individuation  increases ;  the  two  varying  in  inverse 
ratio.  So  little  is  known  regarding  the  physiology  of  fertility  and  of 
nonpathological  sterility,  that  it  is  difficult  to  form  a  correct  opinion  as 
to  the  extent  to  which  the  higher  individuation  directly  affects  fer- 
tility, but  that  it  is  a  factor  to  be  reckoned  with  seems  highly  probable. 

The  average  size  of  the  family  is  small  among  educated  people 
where  acquired  individualization  Is  best  seen.  In  the  families  of  college 
graduates  and  so-called  gentle  people,  in  the  United  States  the  rate  is 
less  than  two  children  to  a  union.  With  the  highly  individuated  late 
marriages,  marriages  of  convenience  rather  than  love  matches,  the 
deliberate  evasion  of  parentage  contributes  largely  to  a  reduction  of 
fertility.  Multiplication  is  affected  more  or  less  indirectly  by  improved 
social  conditions;  new  interests  in  life  have  a  diverting  effect  upon  the 
animal  nature.  There  is  a  constantly  increasing  type  who,  with 
strongly  inhibited  sex  impulses,  are  either  constitutionally  sterile  or 
only  relatively  fertile.  Dr.  Millard  says,  "It  appears  that  poverty, 
degradation,  inefficiency,  ignorance,  overcrowding,  almost  everything, 
in  fact,  that  human  judgment  tends  to  disqualify  for  parenthood,  are 
just  the  factors  nowadays  which  too  often  co-exist  with  large  fam- 
ilies." The  Registrar  General  for  England  has  made  the  important 
statement  that  "not  more  than  seventeen  per  cent  of  the  decline  in  the 
birth  rate  can  be  accounted  for  as  abstinence  from  marriage,  but  that 
nearly  seventy  per  cent  of  the  decline  in  birth  rate  must  be  ascribed 
to  voluntary  restriction." 

Sterility  in  the  Middle  Classes. — The  percentage  of  sterility  in 
the  middle  classes  is  much  higher  than  in  the  class  of  manual  workers, 
and  among  the  latter  the  upper  working  classes  show  a  higher  rate  than 
the  lower.  It  is  thus  quite  apparent  that  those  classes  which  in  the 
past  have  shown  the  greatest  ability  in  the  struggle  for  existence,  by 
rising  in  the  social  scale,  later  fail  to  discharge  their  debt  to  posterity. 

Voluntary  restriction  of  the  birth  rate  for  dysgenic  reasons  enters 
very  largely  into  this  question.    The  present-day  attitude  towards  laige 


8  STERILITY  AND  CONCEPTION 

families  is  changed  and  in  many  households  marriage  is  little  more 
than  legalized  prostitution.  So  frequently  am  I  consulted  by  young 
married  people,  and  even  by  those  contemplating  matrimony,  for  in- 
structions in  methods  of  contraception  that  I  have  many  times  to  blush 
in  very  shame  for  my  country. 

To  obtain  the  best  that  is  in  the  individual  and  for  the  continued 
advancement  of  the  race,  purely  sexual  intercourse  must  be  subor- 
dinated to  the  great  call  of  parenthood,  and  not  the  reverse.  When  a 
couple  enter  into  the  marriage  state,  they  should  accept  willingly,  hope- 
fully, and  with  a  full  realization,  all  of  the  responsibilities  of  common 
parenthood. 

At  a  time  when  large  families  were  the  rule  and  not  the  exception 
as  at  present,  Nature  ruled  and  women  bore  children  whether  or  no, 
so  that  the  population  increased  as  God  intended  it  should.  In  com- 
paratively recent  times  the  death  knell  of  race  advance,  with  "birth 
control"  pulling  strongly  on  the  bell  rope,  has  sounded.  It  is  now  not 
only  among  the  educated  and  professional  classes  where  it  originated 
that  birth  control  is  practiced,  but  it  has  spread  like  wildfire  through- 
out all  classes  until  "race  suicide"  is  now  well  under  way. 

Twenty  years  ago,  on  my  service  at  the  City  Hospital,  the  admis- 
sions to  which  come  from  a  large  area  populated  by  the  middle  and 
lower  class  of  manual  workers,  it  was  a  rare  occasion  to  admit  a 
woman  suffering  from  a  criminally  induced  abortion.  To-day  my 
wards  are  often  crowded  by  this  class  of  patients,  on  many  of  whom 
the  abortion  was  self-induced. 

Eugenics  and  Birth  Control. — Eugenically  speaking  there  is 
much  to  be  said  in  favor  of  birth  control  as  a  therapeutic  measure,  and 
there  should  be  no  foolish  scruples  about  interrupting  a  pregnancy 
when  its  continuance  would  involve  severe  maternal  risk.  I  am  also 
fully  alive  to  the  dangers  and  uncertainties  of  child-bearing  and 
thoroughly  appreciate  that  the  nursing  and  rearing  of  the  child  are 
full  of  tedious  and  anxious  moments,  but  the  whole  subject  deserves 
a  wider  consideration  from  its  economical,  social,  and  ethical  side  than 
it  is  possible  to  devote  to  it  in  a  book  of  this  character. 

There  can  be  but  little  doubt  in  the  mind  of  anyone  to-day  that 
the  gospel  of  sex  hygiene  needs  to  be  widely  preached  by  those  in 
authority  and  not  left  to  the  hysterical  outbursts  of  ignorant  fanatics. 
To  every  young  person,  at  a  suitable  age,  should  be  taught  the  virtue 
of  sex  morality  and  the  sins  of  sex  immorality ;  the  widespread  prev- 
alence of  venereal  diseases  and  their  menace  not  only  to  the  individual 


STERILITY  AND   FERTILITY  9 

but  to  the  marriage  state.  All  should  be  instructed  in  the  immorality 
and  danger  of  criminal  interference  with  pregnancy  and  given  a 
thorough  understanding  of  the  responsibilities  of  parenthood  with  the 
inestimable  value  of  the  home  life  to  the  nation  and  to  the  race. 

From  whatever  point  we  study  the  evolution  of  the  world,  the 
development  of  life  from  a  racial  standpoint,  reproduction,  and  the 
relation  of  parenthood  must  ever  be  kept  in  the  foreground.  It  is  a 
very  vital  and  necessary  factor  in  all  sexual  associations  and  is  a 
primary,  if  not  exclusive,  purpose.  As  a  moral  function,  it  cannot  be 
suppressed  or  disregarded  without  producing  physical  injury  and 
social  unbalance. 

FAMILY  DECREASE 

The  decrease  in  the  size  of  the  family  is  very  materially  contributed 
to  by  the  increasing  economical  difficulties  of  the  great  mass  of  the 
populace.  It  is  on  every  hand  quite  evident  that  as  the  scale  of  pros- 
perity ascends,  the  size  of  the  family  descends,  and  that  whatever 
social  conditions  bring  a  class  into  a  sphere  into  which  they  hope  to 
rise  or  fear  to  fall,  the  lowering  of  the  birth  rate  in  that  class  inevitablv 
follows;  for  a  higher  standard  of  living  with  its  increased  cost  of 
maintenance  brings  with  it  a  taste  for  the  delusive  pleasures  of  a  life 
of  idleness  and  luxury  which  first  points  the  way  to  the  practice  of 
birth  control.  By  a  life  of  luxury  and  ease  the  strength  of  the  repro- 
ductive force  in  man  is  greatly  weakened.  Man  is  an  animal,  to  be 
sure,  but  an  animal  plus  something  more.  Unlike  the  animal,  his 
wants  are  never  satisfied  and  when  once  he  sets  his  foot  upon  the  first 
rung  of  the  ladder  of  infinite  progression,  nothing  will  hold  him  back. 
As  the  power  to  gratify  his  wants  increases,  so  does  his  ambition  grow 
and  the  animal  instincts  within  him,  satisfied  with  only  what  is  neces- 
sary for  its  consumption,  are  crowded  to  the  wall.  Feverishly  he 
renews  his  attacks  upon  the  world,  attempting  to  wrest  from  it  more 
than  he  needs,  more  than  he  can  ever  use,  and  in  many  instances,  more 
than  he  can  ever  even  later  intelligently  give  away.  To  such  a  one  a 
large  family  is  a  decided  encumbrance,  and  it  is  hardly  to  be  wondered 
at  that  for  him  a  declining  birth  rate  holds  little  terror  and  the  question 
of  assuring  the  perpetuation  of  the  race  but  little  interest. 

We  often  hear  the  expression  "a  woman's  sphere"  spoken  of  as  if 
it  were  something  dishonorable  and  entirely  unworthy  of  the  present- 
day  woman.     It  is  to  be  regretted  that  such  an  honorable  state  should 


lo  STERILITY  AND  CONCEPTION 

be  often  derided  and  ridiculed.  There  are,  of  course,  many  spheres  of 
usefulness  for  women  as  well  as  men,  but  there  are  certain  fields  for 
which  she  is  preeminently  fitted  and  in  which  she  conspicuously 
shines.  When  we  consider  the  great  physical  difference  between  the 
sexes  and  the  special  functions  which  each  sex  is  called  upon  to  main- 
tain, it  would  appear  quite  easy  to  understand  that  such  marked  sexual 
characteristics  as  distinguish  between  man  and  woman  would  of  neces- 
sity limit  each  to  their  own  vocations. 

While  it  is  not  to  be  denied  that  woman  may,  and  at  times  does, 
excel  in  many  walks  of  life  which  by  training  and  physical  develop- 
ment might  be  called  masculine,  and  while  it  is  likewise  true  that  men 
oftentimes  excel  in  those  pursuits  or  vocations  supposedly  feminine, 
these  examples  are  as  a  rule  abnormal  and  are  not  to  be  admired  or 
sought  after.  The  woman  lawyer  and  the  man  cook  belong  in  the 
class  with  the  short-haired  woman  and  the  long-haired  man.  Neither 
sex  can  with  safety  disregard  the  physical  demands  made  upon  them, 
and  this  is  particularly  true  of  woman.  When  she  ignores  her  sex 
characteristics,  she  suffers  to  a  greater  extent  than  the  male,  and  such 
divergence  has  a  very  marked  effect  upon  her  progeny  both  in  quality 
and  quantity.  If  her  mind  is  constantly  preoccupied  by  cares  of  state 
or  by  the  mental  excitement  and  mental  trials  of  business,  or  any  other 
occupation  which  tends  to  unsettle  the  proper  balance  between  mind 
and  body,  she  will  not  be  able  to  become  a  mother  of  healthy  children. 

When  woman  attempts  man's  functions  she  proves  to  be  but  an 
inferior  man,  and  the  masculine  woman  is  one  of  the  monstrosities  of 
nature.  To  attempt  to  change  woman  into  half -man  and  half -woman, 
a  hybrid  competing  with,  rather  than  supplementing,  man,  is  to  attempt 
a  "reform  against  nature"  as  Horace  Bushnell  has  truly  said,  and  I 
hardly  believe  the  time  will  ever  come  when  the  line  of  demarcation 
between  the  functions  of  the  sexes  will  be  abolished,  for  such  would 
certainly  be  a  most  disastrous  step  backward  in  the  march  of  social 
progress. 

CREATIVE  AND  DEVELOPMENTAL  DIFFERENCES 

OF  SEX 

The  sexes  show  marked  creative  and  developmental  differences, 
and  it  is  only  when  working  together,  each  in  his  or  her  own  sphere, 
and  not  in  competition,  that  the  best  results  are  obtained.  There 
should  be  no  question  raised  of  superiority,  inferiority,  or  equality,  for 


STERILITY  AND  FERTILITY  ii 

each  Is  superior  in  his  or  her  own  sphere,  and  both  are  essential  to 
life.  There  should  be  a  greater  interest  in  legislation  for  the  protection 
of  women  in  their  legitimate  sphere;  for  motherhood,  both  potential 
as  well  as  actual,  must  be  protected  if  the  race  is  not  to  perish. 

Too  much  attention  has  been  directed  to  legislation  designed  to 
give  women  special  privileges  outside  of  their  own  sphere,  enabling 
them  more  successfully  to  compete  with  men  in  theirs.  It  has  been 
urged  that  in  this  way  would  be  brought  about  the  reform  of  the  race. 
But  if  woman  is  to  save  the  day  and  make  a  better  world,  it  will  be  not 
in  politics  and  business,  but  by  the  side  of  the  cradle,  in  the  nursery, 
in  the  school,  in  the  church  and  around  the  family  fireside. 

There  can  be  no  denying  the  fact  that  higher  civilization  with  its 
increasing  materialism  is  very  hard  on  woman,  and  it  is  devoutly  to  be 
hoped  for  that  this  fact  may  be  more  generally  recognized  before  it  is 
too  late.  The  tendency  of  higher  civilization  is  to  place  woman  upon 
a  high  pedestal,  made  up  of  luxury,  idleness,  and  ease,  the  attendant 
evils  of  which  she  has  not  apparently  as  yet  realized. 

While  every  effort  has  been  made  to  take  her  out  of  her  legitimate 
sphere,  no  effort  has  been  made  to  supply  the  void  which  this  has 
created.  She  is  to-day  only  too  often  driven  by  ambition  towards 
goals  which  she  can  never  reach  because  they  are  physical  impossi- 
bilities for  her  sex.  Thus  stimulated  to  efforts  beyond  her  strength, 
she  is  reduced  to  a  condition  of  nervous  unrest  that  has  lost  to  her 
that  tranquillity  which  means  so  much  when  it  comes  to  a  question  of 
bearing  children. 

If  we  cast  but  a  casual  glance  through  the  animal  kingdom,  we  find 
that  in  all  forms  of  animated  nature,  repose  is  necessary  for  the 
carrying  out  of  any  serious  work,  and  this  is  particularly  important  for 
a  woman  during  her  reproductive  period  when  she  is  concerned  with 
keeping  alive  the  race. 

The  rapid  march  of  progress  in  certain  lines  during  recent  times 
leaves  to-day  very  little  opportunity  for  one  to  sit  down  quietly  and 
adjust  oneself  to  the  constantly  varying  environment,  and  these  inci- 
dental strains  of  everyday  life  tell  more  heavily  on  the  woman  than 
they  do  on  the  man.  Man  has  been  fairly  successful  in  combating  the 
confining  and  retarding  influences  of  civilization  and  survives  to-day 
in  a  fairly  healthy  and  vigorous  condition.  I  wish  that  I  felt  equally 
as  sure  regarding  woman,  but  I  feel  that  her  ill-regulated  life,  if  not 
remedied  soon,  will  lead  to  a  very  marked  degeneration,  and  through 


12  STERILITY  AND  CONCEPTION 

this  degeneration  of  woman  will  be  brought  about  the  degeneration  of 
the  race. 

Decay  of  Parental  Supervision. — One  of  the  saddest  features 
that  we  are  witnessing  to-day  is  the  apparent  gradual  decay  of  the 
parental  interest,  for  the  presence  of  children  in  the  household  is  the 
strongest  factor  in  maintaining  the  happiness  and  integrity  of  the 
home,  and  in  the  development  of  the  home  life,  so  vital  to  the  advance 
of  the  race.  To-day,  in  spite  of  all  the  thought  and  care  devoted  to 
children,  and  there  has  probably  never  been  an  era  in  the  history  of 
the  world  when  such  intense  interest  has  been  aroused,  the  actual  num- 
ber of  men  and  women  who  become  parents  is  rapidly  decreasing, 
while  the  average  number  of  children  to  each  union  has  fallen  below 
the  minimum  of  previous  generations. 

Decrease  in  Marriages. — There  has  been  a  very  marked 
decrease  in  the  number  of  marriages,  accompanied  by  a  great  increase 
in  the  number  of  divorces.  In  the  United  States  the  ratio  of  divorce 
to  marriage  is  i  to  185 ;  in  England,  i  to  1 1,000;  while  in  Canada  there 
is  but  one  divorce  to  every  63,000  marriages.  Dr.  J.  S.  Billings  has 
said,  "It  is  probable  that  the  most  important  factor  in  the  change  in 
the  birth  rate  is  the  deliberate  and  voluntary  avoidance  or  prevention 
of  childbearing  on  the  part  of  a  steadily  increasing  number  of  married 
people."  Englemann,  as  a  result  of  extensive  study  of  the  subject, 
arrived  at  the  conclusion  that  the  percentage  of  childless  marriages 
in  the  United  States  increased  in  the  nineteenth  century  from  two  per 
cent  to  over  twenty  per  cent.  Just  what  it  would  be  to-day  is  difficult 
of  estimation,  but  there  is  little  to  lead  one  to  believe  but  that  it  has 
steadily  progressed. 

Idealization  of  Motherhood. — A  sufficient  idealization  of 
motherhood  has  not  been  held  up  before  our  girls,  and  woman  is 
daily  pictured  in  almost  every  role  but  that  of  mother.  Dawson 
emphasizes  this  fact  none  too  strongly  when  he  says,  "It  is  woman  as 
academician^ — excelling  in  scholarship,  taking  degrees,  traveling  in 
Europe  in  pursuit  of  some  specialty,  and  finally  entering  upon  a  pro- 
fessional career  of  some  kind — that  becomes  the  ideal  of  thousands  of 
our  brightest  girls  and  young  women  in  schools,  colleges,  and  uni- 
versities. It  is  woman  in  public  life — as  club  woman,  author,  actress, 
social  reformer,  or  political  agitator — that  bulks  up  most  conspicuously 
in  the  public  imagination  as  doing  the  things  that  are  really  worth 
while  for  the  woman  of  the  present  age."  He  goes  on  to  say  further, 
"It  is  the  detached  woman,  whom  one  sees  everywhere,  who  is  influ- 


bTERILITY  AND   FERTILITY  13 

encing  most  profoundly  the  ideals  of  woman's  character  and  function 
in  the  world.  These  detached  women  are  the  heroines  of  novels,  the 
central  figures  on  the  stage,  the  subjects  of  all  kinds  of  popular  art. 
It  is  not  the  Madonna  that  we  see  on  the  covers  of  current  literature,  in 
the  half-tones  of  magazines  and  newspapers,  in  the  social  columns 
of  the  daily  press,  or  in  the  fashion  plates.  Street  life,  indeed  and 
travel  are  interesting  indices  in  this  connection.  Here  the  woman  with 
the  lines  of  maternity  in  face  and  form  has  well  nigh  disappeared, 
except  in  rural  communities,  and  in  those  parts  of  our  cities  where  the 
foreign  population  still  keeps  alive  the  interests  and  customs  of  naive 
motherhood.  Everywhere  in  the  thronging  thoroughfares  of  city  life, 
about  stations  and  on  railroads  and  steamship  lines,  we  see,  not 
Madonnas,  but  all  sorts  of  nondescript  social  corsairs,  rushing  hither 
and  thither  in  modish  dress  that  not  infrequently  symbolizes  the  sacri- 
fice of  that  physical  development  and  health,  and  intellectual  and  moral 
qualities  which  make  women  efficient  mothers  of  a  race  of  men." 

Organized  Birth  Control. — This  subsidence  of  parental  desire 
should  be  met  at  every  turn  and  strongly  combated  by  more  enlight- 
ened and  intelligent  propaganda.  Our  young  must  be  brought  up  in 
an  atmosphere  where  the  refining  and  ennobling  influence  of  the  home 
life  will  later  on  make  their  education  in  sex  matters  more  easy  of 
accomplishment,  thus  leading  to  a  naturally  reverent  attitude  towards 
propagation. 

Dr.  Englemann  says,  "There  is  no  question  as  to  the  baneful 
sentiment  which  is  gradually  developing  among  people  that  bearing 
children  belongs  to  low  life  and  is  degrading,  which  now  and  then 
becomes  evident  in  aspersions  cast  upon  those  with  large  families, 
implying  that  their  life  is  vulgar  and  sensual." 

The  propaganda  of  the  numerous  Voluntary  Parenthood  Associa- 
tions and  Birth  Control  Societies  is  replete  with  such  statements  as 
"woman's  inferior  status  as  a  brood  animal  for  the  masculine  civiliza- 
tion of  the  world,"  "A  dominated  weakling  in  society  controlled  by 
men."  These  are  tempting  bait  that  hook  many  an  unwary  one  of 
both  sexes  and  appeal  strongly  to  unwilling  mothers  who  have  felt 
the  "inner  urge"  calling  loudly  for  a  "wider  freedom"  to  develop  "fully 
rounded  lives."  In  full  cry,  close  upon  their  heels,  comes  the  usual 
assortment  of  long-haired  men  and  short-haired  women,  eager  to  enroll 
under  any  banner  on  which  the,  to  them,  magic  word  sex  is  inscribed. 

In  novels,  magazines,  public  addresses,  and  almost  everywhere 
to-day  where  the  human  language  is  written  or  spoken,  do  we  find 


U  STERILITY  AND  CONCEPTION 

such  sentiments  voiced,  and  it  is  often  openly  asserted  that  motherhood 
is  a  confining  and  retarding  state  of  slavery,  "an  impertinent  inter- 
ference with  private  rights." 

It  is  devoutly  to  be  hoped  that  this  very  apparent  subsidence  of 
interest  in  motherhood  as  an  institution  is  only  a  transitory  phase  in 
our  advancing  civilization  and  that  the  desire  for  motherhood  with  a 
realizing  sense  of  all  that  it  means  to  the  race  will  again  assert  itself. 
However  praiseworthy  may  be  the  intensive  scientific  and  philan- 
thropic study  of  children,  and  I  would  not  for  a  moment  belittle  the 
honest  efforts  of  those  working  in  this  field,  it  is  yet  true  that  our 
declining  birth  rate  is  of  paramount  importance,  for  you  must  first 
catch  the  child  before  you  can  rear  it. 

If  a  couple  do  not  wish  to  have  children,  then  life  at  its  very 
beginning  is  the  result  of  an  accident,  and  further  development  is  only 
too  often  greatly  handicapped  by  a  surrounding  haze  of  parental 
selfishness. 

The  Era  of  the  Child. — One  of  the  most  encouraging  move- 
ments of  the  present  time  is  the  scientific  and  eugenic  interest  that  has 
been  taken  in  children,  and  just  as  this  century  has  been  largely  a 
woman's  era,  the  next  century  bids  fair  to  be  one  of  the  child. 

Home  Life. — The  hope  of  the  future,  it  would  seem,  lies  in 
meeting  the  growing  materialism  of  the  city  by  the  development  of  the 
home  life  in  the  country  and  suburban  districts.  The  preservation  of 
the  nation  will  depend  upon  the  great  middle  class,  those  who  have 
risen  above  the  confining  and  retarding  environment  of  poverty,  but 
have  not  acquired  the  idle,  migratory  habits  of  the  rich.  The  ultimate 
result  under  our  present  social  conditions  rests  with  the  woman.  To 
her  should  be  made  the  last  appeal,  so  that  whether  we  rise  or  fall  the 
final  responsibility  may  rest  upon  the  proper  shoulders. 

It  has  been  aptly  said  that  "great  nations  are  not  destroyed  but 
commit  suicide,"  and  when  women  realize  fully  this  fact  and  are 
called  upon  to  save  the  race,  I  feel  certain  that  the  call  will  not  be  in 
vain. 

LITERATURE 

BiGLOW.    Obst.  Gazette.    Jan.  1883. 

Dawson.    The  Right  of  the  Child  to  Be  Well  Bom.  191 2. 

Englemann,  G.  J.    Labor  among  Primitive  Peoples.  1882. 
Englemann,  G.  J.    Journal  Am.  Md.  Assn.     1901. 


STERILITY  AND  FERTILITY  15 

English  National  Birth  Rate  Commission.     Second  Report,  1920. 

Grassmann.    All.  Zeitschrift  f.  Psychiatric.    1896. 

Haeckel,  Ernst.     Die  Weltrathsel.     1900. 

Haggard,  H.  R.    Report  of  English  Birth  Rate  Commission.  1920. 

Harrison,  L.  W.    Journal  of  Sanitary  Institute.     19 19. 

HuLST,  M.  M.    Quart.  Publ.  Am.  Statist.  Assn.     1921. 

March  ANT.     The  Control  of  Parenthood.     1920, 

Ploss,  H.    Das  Weib.     1902. 

Sanger,  Margaret.    Woman  and  the  New  Race.    1920. 

Spencer,  Herbert.     Principles  of  Biology.     1901. 

Strong,  Josiah.    The  Thirtieth  Century  City.     1892. 

Taylor,  C.  F.    A.  J.  O.    Jan.  1882. 

United  States  Census  Bureau  Report.     1920. 

Witterman.  Zeitschrift  f.  d.  ges.  Neurologic  u.  Psychiatric.  1913. 


CHAPTER  II 


ORIGIN  OF  LIFE 


Harvey's  aphorism,  "Omne  vivum  ex  ovo" — Weismann's  theory  of  germ  plasm- 
Theories  of  preformation — Fission — The  ovum — Microscopy  of  the  germ  cells- 
Schulte's  definition  of  the  cell. 


"OMNE  VIVUM  EX  OVO" 

Many  years  have  passed,  over  three  hundred  in  all,  since  Harvey 
formulated  this  aphorism.  His  pioneer  study  in  the  field  of  ovulation, 
carried  out  in  the  seventeenth  century,  led  him  to  the  conclusion  that 
all  life  comes  from  an  egg;  and  with  few  exceptions,  all  experiments 
and  investigations  since  that  time  have  but  tended  to  prove  the  truth 
of  his  original  assertion.  While  the  statement  that  "every  living  thing 
comes  from  an  egg"  may  not  be  strictly  true,  it  can  well  be  accepted 
in  the  majority  of  cases. 

Weismann's  Theory  of  Germ  Plasm. — Weismann  in  his 
"Germ-Plasm"  says:  "Long  before  the  mountains  were  brought  forth, 
or  even  the  dry  land  appeared,  and  while  the  earth  was  still  only  a  wide 
waste  of  waters,  there  was  formed  within  these  waters  the  essence  of 


Fig.  I. — Formation  of  Polar  Body  (Sobotta)  X500.     n.,  nucleus;  v.,  vitelline  mem- 
brane; y.,  yolk  granules;  p.,  polar  spindle;   s.,  head  of  spermatozoon  (Williams). 

life  enclosed  within  a  minute  cell.  That  life  during  all  the  hundred 
million  years  since  the  Laurentian  period  has  never  died.  Accident 
may  have  eliminated  many  of  its  offshoots,  but  the  essence  of  the  life 
remains." 

16 


ORIGIN  OF  LIFE 


17 


Theories  of  Preformation. — The  manner  in  which  the  child  is 
formed  in  the  mother's  womb,  how  animals  evolve  from  ova,  and  why 
the  plant  springs  from  the  seed  are  all  questions  of  absorbing  interest, 
and  they  have  occupied  many  thoughtful  minds  for  thousands  of  years. 
But  the  whole  question  is  so  complex  that  it  is  not  surprising  to  find  it 
mixed  in  an  almost  hopeless  tangle  of  fables  and  errors.  Most  of  the 
older  scientists  who  studied  the  subject  were  possessed  with  the  idea 
that  the  complete  individual,  with  all  its  parts,  lay  contained  in  the 
ovum,  and  that  all  further  development  was  nothing  more  or  less  than 
a  gradual  unfolding  of  parts  that  were  already  infolded. 

This  preformation  theory  obtained  general  acceptance  for  many 
years,  and  as  logical  consequence  there  arose  in  the  last  century  the 
further  theory  of  Scatulation,  which  held  the  interest  and  attention  of 
many  thoughtful  biologists  of  the  period,  and  for  some  time  it  was 
believed  that  the  outlines  of  the  entire  organism,  with  all  its  parts  was 
present  in  the  tgg,  and  that  the  ovary  of  the  embryo  contained  the  ova 
of  the  following  generation,  these  again,  the  ova  of  the  next,  and  so 
on  ad  infinitum. 

On  this  basis,  the  distinguished  physiologist  Haller  calculated  that 
God  had  created  on  the  sixth  day  of  His  creatorial  labors,  6000  years 
before,  the  germs  of  two  hundred  billion  individuals  and  had 
ingeniously  packed  them  all  away  in  the  ovaries  of  Mother  Eve. 

,-'P  ^ 

■■T> 
-P. 

P. 


BI^ 


Fig.  2. — Formation  of  Female  Pronucleus  and  its  Fusion  with  Male  Pronucleus 
(Sobotta)  X500.  p.,  polar  body;  f.p.  female  and  m.p.,  male  pronucleus;  p.n., 
pronuclei  about  to  fuse  (Williams). 

Fission. — While  it  is  true  that  we  are  unable  to  find  in  the  life 
history  of  many  of  the  protozoa,  or  one-celled  animals,  and  also  in 
quite  a  large  number  of  the  metazoa,  or  multi-cellular  animals,  any 
evidence  of  egg  formation;  still  the  majority  of  animals  do  arise  from 
a  single  cell,  or  ovum.  Those  protozoa  and  metazoa  that  are  excep- 
tions to  the  general  rule  develop  by  fission,  a  division  of  the  parent 
individual,  or  by  buds,  outgrowths  from  the  parent  stem. 


i8 


STERILITY  AND  CONCEPTION 


The  Ovum. — As  a  rule  the  female  sex-cell,  or  ovum,  is  unable 
properly  to  develop  and  fulfill  its  destiny  in  nature  unless  fertilized  by 
the  male  sex-cell.  In  order  that  fertilization  may  take  place,  it  is 
necessary  for  the  male  sex-cell,  or  spermatozoon,  to  penetrate  the 
female  sex-cell.  When  such  penetration  occurs  between  the  two  sex- 
cells,  fusion  results,  and  the  single  cell  resulting  is  known  as  a  zyote. 
The  metamorphosis  that  takes  place  in  this  single  cell  after  fertilization 
is  a  marvelous  change,  and  the  further  development  from  a  minute 
and  apparently  simple  cell  into  the  development  of  a  large  complex 
organized  individual  is  one  of  the  most  remarkable  of  Nature's  many 
wonderful  phenomena. 

As  has  been  stated,  many  of  the  older  scientists  were  firm  in  their 
belief  that  a  miniature  of  the  mature  individual  was  present  in  the 
ovum,  and  that  further  development  consisted  only  in  the  growth  and 
expansion  of  structures  already  preformed.  It  was  but  in  the  nature 
of  things  that  this  belief  should  not  long  continue  after  the  publication 
of  the  researches  made  by  Caspor  Friedrich  Wolff  in  1759.  He  proved 
most  conclusively  that  the  adult  structures  developed  gradually  from 
what  is  apparently  undifferentiated  material.    In  other  words,  that  the 


'gZOk. 


FlG.  3. — Changes  in  the  Segmented  Nucleus  (Sobotta)  X500.    p.,  polar  body., 
s.n.,  segmented  nucleus  (Williams). 


development  is  epigenetic.  But  epigenesis,  however  ingenious  in 
theory,  does  not  altogether  explain  development  by  simply  asserting 
that  it  occurs. 

Following  the  theor}'  of  epigenesis,  a  new  one  was  gradually 
evolved,  that  of  predetermination.  This  theory  for  many  years  held 
the  attention  of  investigators  and  played  an  important  part  in  the 
conception  of  development. 

Microscopy  of  the  Germ  Cell. — When  we  enter  into  a  micro- 
scopic study  of  the  germ  cells,  it  is  found  that  they  possess  a  very 
definite  amount  of  organization,  and  that  the  zyote  contains  within 


ORIGIN  OF  LIFE 


19 


itself  certain  structures  contributed  by  the  ovum,  as  well  as  certain 
other  structures  contributed  by  the  spermatozoon.  The  human  fer- 
tilized ovum  is  but  a  bundle  of  potentialities.  Its  further  growth, 
while  in  its  host,  the  mother,  follows  along  certain  very  definite  physio- 
logical lines. 

As  far  as  is  known,  living  matter  never  arises,  nor  is  it  ever 
formed,  except  from  preexisting  living  matter.  As  the  original 
structures  of  the  zyote  determine  the  characteristics  of  the  individual 
that  arises  from  it,  it  is  probable  that,  to  a  certain  extent,  all  develop- 
ment is  predetermined.  On  the  other  hand,  the  fact  must  not  be  lost 
sight  of  that  development  is  also  epigenetic  and  that  our  modern  con- 
ception should  include  certain  factors  of  both  theories. 

The  cell  is  the  simplest  particle  of  matter  that  is  able  to  maintain 
itself  and  to  reproduce  others  of  its  kind,  and  the  simplest  method  of 
reproducing  known  is  that  of  fission. 

This  is  well  exampled  in  the  case  of  the  small  form  of  marine  life 
known  as  the  ameba.  The  ameba  is  a  mass  of  protoplasm  that  feeds, 
grows,  moves  about,  takes  to  itself  oxygenated  water  and  rids  itself 
of  waste  material,  demonstrating,  in  fact,  all  the  essential  phenomena 
of  internal  and  external  relationship.  While  it  does  not  exhibit  any- 
thing more  than  a  general  irritability,  it  yet  answers  to  stimuli  from 
without  and  presents  us  with  quite  a  true  counterpart  of  changes  that 
occur  in  ourselves  when  we  are  acted  upon  by  outside  stimuli. 


Pig.  4. — Formation  of  Mulberry  Mass  (Sobotta)  X500  (Williams). 

The  ameba  performs  all  the  actions  that  are  essential  to  our  idea  of 
an  individual  existence,  but  it  does  more  than  this,  it  performs  also  the 
functions  necessary  for  the  continuance  of  the  species  to  which  it 
belongs.  It  reproduces  itself  in  a  way  that  gives  us  a  readily  under- 
standable idea  of  the  simplest  method  of  reproduction.  Its  nucleus 
elongates,  becomes  constricted  in  its  middle,  and  divides  into  two. 
While  this  division  is  being  effected,  the  surrounding  protoplasm 
divides  into  two  masses,  each  of  which  accompanies  one  of  the  nuclei, 


I 


20  STERILITY  AND  CONCEPTION 

and  as  a  result  of  this  process,  two  individuals  are  formed  where 
before  there  was  only  one.  Each  one  differs  from  its  original  parent 
ameba  only  by  its  smaller  size,  and  as  the  original  ameba  has  alto- 
gether disappeared,  being  to  all  practical  purposes,  dead,  we  have  in 
this  simple  method  of  reproduction  the  death  of  the  parent  contem- 
poraneous with  the  appearance  of  the  new  generation. 

Schultze's  Definition  of  the  Cell. — Max  Schultze  was  the  first 
to  define  the  cell  as  a  mass  of  protoplasm  containing  a  nucleus.  But 
his  definition  must  be  somewhat  modified,  as  the  existence  of  many 
cells  without  distinct  nuclei  has  since  been  demonstrated.  While  some 
cells  have  no  distinct  nucleus,  they  yet  have  a  certain  amount  of 
nuclear  material  in  their  composition.  The  definition  of  a  cell,  to  be 
more  exact,  would  be  "A  mass  of  protoplasm  containing  nuclear 
material."  Cells  vary  greatly  in  size,  all  the  way  from  -^—  to 
—^  of  an  inch  in  diameter,  and  many  examples  as  large  as  several 
inches  in  length  occur.  The  size  of  the  cell  depends  largely  upon  the 
amount  of  nutritive  substance  which  it  contains.  This  nutritive  material 
is  present  as  food  supply  for  the  growing  cell.  The  shapes  of  cells  vary 
as  well  as  the  size,  and  while  they  are  frequently  spherical,  the  major- 
ity are  not.  The  manner  in  which  cells  increase  in  number  is  by 
division,  either  direct  or  indirect. 

In  all  forms  of  life,  whether  plant  or  animal,  there  are  two  dom- 
inant characteristics  standing  out  clearly  over  all  others.  These  are 
assimilation  and  reproduction.  It  matters  little  how  widely  separated 
in  the  process  of  evolution  these  may  be,  the  same  means  are  always 
used  to  accomplish  the  same  ends.  Sex  is  the  great  controlling  influ- 
ence, and  the  sexual,  the  most  common  method  of  reproduction  in  all 
forms  of  life,  whether  plant,  animal,  or  man. 

LITERATURE 

Bell,  F.  J.    Comparative  Anatomy  and  Physiology.     1885. 

Darwin,  Chas.    Origin  of  Species.     1890. 

Haeckel,  Ernst.    Die  Weltrathsel.     1901. 

Hegner.    Germ  Cycle  in  Animals.     19 14. 

Stockard,  C.  R.    Proc.  Soc.  Exper.  Biology  and  Medicine.    1914. 

Stromayer.    Miinch.  Med.  Wochenschrift.     1901. 

Weismann,  Aug.    The  Germ-plasm.    1893. 


CHAPTER   III 
DEVELOPMENT  OF  THE  FEMALE  CELL 

The  ovaries — The  corpus  luteum — Endocrine  function  of  the  corpus  luteum — Dual 
function  of  the  ovary — The  so-called  corpus  luteum  of  pregnancy — Case  report 
— Ovulation — Potential  immortality  of  protozoa — Ovulation  in  its  relation  to 
fertilization. 

The  Ovaries. — The  ovaries,  two  in  number,  He  laterally  in  the 
woman's  pelvis,  being  connected  with  the  posterior  face  of  the  broad 
ligament  and  with  the  uterus.  Two  functions  are  usually  attributed 
to  these  glands;  the  one  relates  to  reproduction  and  is  intimately  con- 
cerned with  the  development  of  the  ova;  the  other  has  to  do  in  some 
way  with  the  general  body  function,  thereby  placing  the  ovary  in  the 
class  of  internal  secretory  organs.  When  the  ovary  is  considered  from 
this  point  of  view,  two  widely  different  histological  structures  are  to 
be  distinguished — the  corpus  luteum  and  the  interstitial  cells. 

The  Corpus  Luteum. — The  corpus  luteum  was  first  recognized 
by  Goiter  as  early  as  the  sixteenth  century,  while  the  interstitial  cells 
were  not  described  until  about  the  middle  of  the  nineteenth  century 
(1863),  following  the  studies  of  Pfliiger. 

Endocrine  Function  of  the  Corpus  Luteum. — Beginning  with 
the  work  of  Frankel,  multitudinous  reports  on  the  endocrine  functions 
of  the  corpus  luteum  have  been  published,  and  the  question  of  the 
functions  of  the  interstitial  tissues  has  been  extensively  worked  up  by 
Frankel,  Regard,  Graves,  Felner,  and  many  others. 

It  may  now  be  taken  as  an  established  fact  that  the  ovary  performs 
a  dual  function ;  namely,  the  liberation  of  the  germ  cell,  and  the  forma- 
tion of  an  internal  secretion,  so  called,  which  remains  in  the  body. 
The  liberation  of  the  germ  cell  is  directly  concerned  with  the  perpetua- 
tion of  the  species,  while  the  so-called  internal  secretion  passes  into  the 
blood,  by  it  is  carried  to  distant  parts  of  the  body,  and  exerts  a  power- 
ful eflfect  upon  the  development  and  nervous  control  of  the  individual. 

Though  not  necessary  to  the  life  of  the  woman,  the  ovary  is,  in 
many  respects,  one  of  the  most  important  organs  in  her  whole  body, 

21 


33 


STERILITY  AND  CONCEPTION 


and  its  sexual  value  should  not  be  underestimated.  Chipman  says: 
"Not  only  is  it  the  primary  organ  concerned  in  the  reproductive  cycle, 
but  it  also  regulates  and  controls  the  complete  attainment  of  develop- 


FiG.  5. — Diagram  of  a  Holoblastic  Ovum  (^4)  and  a  Meroblastic  Ovum  (B).    The 
yolk  or  food  material  is  represented  in  both  by  clear  globxoles    (Quain). 

ment,  growth,  and  function  in  the  individual  herself.  It  so  perfects 
its  own  generation,  while  at  the  same  time  it  prepares  for  the  next. 
Supreme  individuality  is  only  attained  through  its  influence,  and  with- 
out it  this  attainment  is  never  reached,  and  the  individual  remains 


Fig.  6. — First  Stages  of  Segmentation  of  a  Mammalian  Ovum;  Semi- Diagram- 
matic (Drawn  by  AUen  Thomson  after  E.  V.  Benedin's  description)  (Quain).  zp., 
zona  pellucida;  p.gl,  polar  globules;  a,  division  into  two  segments;  etc,  larger  and 
clearer  segment;  ent,  smaller,  more  granular  segment;  b,  stage  of  four  segments; 
c,  eight  segments,  the  ectomeres  partially  enclosing  the  entomeres;  d.c,  succeeding 
stages  of  segmentation  showing  the  more  rapid  division  of  the  clearer  s^n^ients  and 
the  inclosure  of  the  darker  segments  by  them. 

imperfect  and  incomplete.  Moreover,  its  continual  presence  is  essen- 
tial to  the  maintenance  of  this  individual  or  sex  perfection;  and  its 
removal  or  its  disablement,  even  after  maturity  is  reached,  leads 
inevitably  to  descent  or  retrogression." 


DEVELOPMENT  OF  THE  FEMALE  CELL  23 

The  ovary  being  a  part  of  the  very  important  system  of  internal 
secretory  glands,  its  secretion  or  secretions  react  to  a  very  marked 
degree  upon  the  general  metabolism  of  the  body,  exerting  a  particular 
action  upon  nutrition,  growth,  and  function  of  the  uterus. 

I  firmly  believe  with  Frankel,  Edin,  Lockyer,  and  others  that  the 
corpus  luteum  rather  than  the  interstitial  tissue  is  concerned  with  the 
rise  and  control  of  menstruation  and  that  the  so-called  corpus  luteum 
of  pregnancy  is  but  the  persistence  of  a  pathologically  enlarged  corpus 
luteum.  The  presence  of  a  large,  cystic  corpus  luteum  is  invariably 
associated  with  frequent  and  profuse  menstruation  which  promptly 
returns  to  normal  after  the  pathological  growth  is  removed.  This  I 
have  had  opportunity  to  prove  many  times  in  operating  on  these  cases. 
In  support  of  this  view  I  give  the  following  case  history  of  the  most 
interesting  and  instructive  example  of  this  condition  that  I  have  ever 
met  with: 

Mrs.  G.  J.,  age  twenty- seven.  Menstruation  regular  since  the  age  of  fifteen. 
During  her  eight  years  of  married  life  she  had  had  three  children  and  five  mis- 
carriages and  one  abdominal  operation  for  the  removal  of  diseased  left  adnexa. 
In  igii  I  operated  upon  her  for  continuous  right  pelvic  pain.  At  this  time  the  right 
tube  and  ovary  were  found  prolapsed  and  buried  in  dense  velamentous  adhesions. 
These  were  freed,  the  tube  opened  and  the  ovary  sutured  to  the  upper  body  of 
broad  ligaments.  The  round  ligaments  were  shortened  and  the  appendix  removed. 
Inspection  of  the  left  side  showed  a  free  broad  ligament  surface  with  no  evidence 
of  either  tube  or  ovarian  remains.  Convalescence  was  uneventful.  The  patient 
remained  well  for  about  two  years  when  she  was  taken  suddenly  with  symptoms 
of  acute  intestinal  obstructions  Prompt  operation  on  December  20,  1913,  disclosed 
the  point  of  obstruction  to  be  in  a  coil  of  the  small  intestine  adherent  between  the 
right  ovary  and  broad  ligament.  This  ovary  had  become  cystically  enlarged  since 
the  previous  operation  and  after  being  freed  from  the  intestinal  adhesions  was 
removed  entire  with  the  tube.  Following  this  operation  the  patient  continued  to 
bleed  from  the  uterus  regularly  and  at  times  profusely  for  the  next  year  and  a  half, 
and  was  again  operated  upon  in  January,  1915,  at  the  Woman's  Hospital.  At  this 
time  a  thorough  search  was  made  for  any  ovarian  tissues  that  might  account  for 
the  regular  menstruation  which  the  patient  had  been  having,  and  both  broad 
ligaments  were  seen  to  be  free  and  clear  from  any  evidence  of  ovarian  tissue. 
A  subtotal  removal  of  the  uterus  was  then  performed  and  during  this  operation 
a  small  cyst  about  one  inch  in  diameter,  having  the  appearance  of  a  corpus  luteum 
cyst,  being  lined  with  a  thick  layer  of  yellow  lutein  tissue,  was  removed  from 
between  the  folds  of  the  right  broad  ligament.  This,  with  the  uterine  corpus,  was 
submitted  to  the  laboratory  for  examination  and  report.  Convalescence  was 
uneventful  and  the  pathological  report  on  the  specimens  was  as  follows : 

Spec.    Uterus.     Ovarian  tissue. 

Diag.  Adenomyometritis  uteri — premenstrual  change  in  the  mucosa.  Cystic 
corpus  luteum. 

Exam.     MACROSCOPICAL :— Uterus  with  round  Hgaments. 

Uterus  measures  about  5X5X3  cm.    The  myometrium  is  thickened,  mucosa  is 


24  STERILITY  AND  CONCEPTION 

hyperplastic,  especially  in  the  fundus.  The  stump  of  the  tube  is  rather  hyperemic. 
In  the  lower  portion  of  the  corpus  we  notice  a  slight  prominence  in  the  mucosa. 
On  section,  a  small  cyst  of  about  J4  cm.  diameter,  filled  with  bloody  liquid  is 
situated  in  the  center  of  the  myometrium. 

The  ovarian  tissue  consists  of  a  slightly  cystic  corpus  luteum  of  pregnancy. 
There  is  not  much  blood  in  the  cavity,  but  mucus  is  present.  The  layer  of  granulosa 
cells  is  thick  and  well  preserved.  In  most  places  the  theca  interna  and  externa 
surround  the  granulosa  layer.  There  is  also  some  hemorrhagic  vascular  fibrous 
tissue  present  at  one  area  which  has  no  special  characteristics  typical  for  the 
ovary.  This  stroma  is  scant  and  contains  no  follicles.  The  sections,  therefore, 
consist  almost  wholly  of  corpus  luteum  constituents  with  only  a  minute  amount  of 
ovarian  stroma  at  one  point. 


OVULATION 

Under  ovulation  is  included  the  growth,  development,  and  ultimate 
rupture  of  the  graafian  follicles.  The  direct  causative  factor  in  bring- 
ing about  this  rupture,  which  results  in  the  discharge  of  the  ovum,  is 
still  more  or  less  of  an  open  question.  During  the  life  of  the  ovary 
immature  follicles  are  found  at  or  near  the  center  of  the  ovary,  which, 
as  they  mature,  grow  in  size  and  leave  the  central  zone,  approaching 
the  periphery  of  the  ovary.  When  the  periphery  is  reached,  the  follicle 
pushes  it  outward,  producing  a  very  pronounced  bulging  at  this  point. 
The  ovarian  stroma  is  pushed  aside,  and  the  tunica  albuginea,  with  the 
overlying  epithelium  and  blood  capillaries,  become  much  thinned  as  a 
result  of  this  compression. 

It  is  generally  supposed  that  this  pressure  so  interferes  with  the 
nourishment  of  the  ovarian  stroma  as  to  result  in  a  pressure  atrophy, 
and  that  this  atrophy  so  reduces  the  resistance  of  the  tissue  that  it  is 
finally  overcome  and  the  distended  follicle  then  bursts,  discharging  its 
contents  into  the  peritoneal  cavity;  It  is  quite  possible,  as  the  experi- 
ments of  Schocker  would  seem  to  indicate,  that  ovulation  is  due  to  a 
specific  enzyme. 

Protozoal  Immortality. — Weismann  believed  that  protozoa 
are  potentially  immortal  as  germ  cells.  Maupas  demonstrated  the  fact 
that  there  were  various  kinds  of  infusoria  that  did  not  propagate 
definitely  by  fission,  but  that  a  sexual  influence  was  at  times  necessar}\ 
Calkin  has  shown  that  regular  periods  of  depression  arise,  and  that 
while  a  spontaneous  regeneration  from  the  effects  of  such  depressions 
might  take  place,  artificial  stimulation  can  be  made  to  aid  greatly  the 
animals  in  overcoming  critical  periods.  In  many  instances,  the  depres- 
sion periods  proved  fatal  unless  there  was  such  a  sexual  stimulation. 


DEVELOPMENT  OF  THE  FEMALE  CELL  25 

Wooclruff,  by  selecting  conditions  of  environment  closely  simulat- 
ing those  of  nature,  was  able  to  keep  alive  almost  indefinitely  without 
any  sexual  stimulation  whatever  a  certain  strain  of  paramaecium. 
This  would  lend  belief  to  the  truth  of  the  theory  of  the  potential 
immortality  of  the  protozoa  of  Weismann. 


OVULATION  AND  FERTILIZATION 

It  is  most  probable  also  that  ovulation  corresponds  more  or  less 
closely  with  fertilization  and  occurs  at  intervals  throughout  the  month, 
perhaps  not  even  excepting  the  latter  days  of  the  actual  period  of  the 
menstrual  discharge.  A  further  inference  is  perhaps  justifiable  that 
ovulation  and  menstruation  may,  but  do  not  necessarily  coincide.  This 
is  supported  by  the  researches  of  Bland-Sutton  and  Heape  on  men- 
struation of  monkeys  and  baboons,  who  have  shown  that  in  these  ani- 
mals menstruation  and  ovulation  do  not  necessarily  take  place  at  the 
same  time.  Furthermore,  it  is  strengthened  by  the  observations  made 
by  gynecological  surgeons  in  the  course  of  operations:  viz.,  that 
apparently  ripe,  or  recently  ruptured  graafian  follicles  are  found  in  the 
ovary  at  various  times  of  the  intermenstrual  period,  while  on  the  other 
hand,  there  is  frequently  no  trace  of  either  ripe  or  recently  ruptured 
follicles  found  immediately  after  the  menstrual  period. 

It  is  now  generally  admitted  that  the  menstrual  cycle  in  woman 
and  in  the  female  monkeys  is  homologous  with  the  estrus  cycle  of  the 
lower  mammals.  The  estrus  cycle  is  divided  by  Heape  into  proestrum, 
estrus  and  diestrum.  During  proestrum  the  generative  organs  of  the 
female  show  signs  of  special  activity,  such  as  swelling  of  the  vulva, 
with  a  coloration  or  flushing  of  its  surroundings,  and  a  discharge  of 
blood  or  mucus  from  the  vagina.  This  is  immediately  followed  by  the 
"estrus,"  or  "period  of  desire,"  during  which  only  is  the  female 
capable  of  impregnation  and  will  receive  the  male.  If  pregnancy  does 
not  occur  the  estrus,  after  a  brief  space  in  which  desire  subsides,  is 
succeeded  by  a  period  of  quiescence,  or  diestrum,  which  lasts  until 
proestrum  again  sets  in.  Menstruation  in  the  human  female  'is 
homologous  with  the  proestrum.  Though  there  is  no  fixed  "period 
of  desire,"  there  is  still  an  indication  that  a  vestige  of  this  persists,  as 
denoted  by  the  fact  that  a  phase  of  more  pronounced  estrum  commonly 
succeeds  the  cessation  of  menstruation.  It  is  quite  clear  from  the 
results  of  comparative  methods  that  the  significance  of  menstruation 


36 


STERILITY  AND  CONCEPTION 


does  not  lie  in  the  mere  periodic  growth  and  subsequent  destruction  of 
the  mucous  membrane,  but  in  the  cycle  as  a  whole.  The  essence  of  the 
process  is  not  the  preparation  of  a  menstrual  decidua,  but  the  forma- 
tion of  a  new  endometrium. 

In  the  case  of  most  lower  mammals,  the  generative  organs  lie 
dormant  through  a  large  part  of  the  year,  and  when  the  breeding 
season  approaches,  the  endometrium  undergoes,  in  the  proestrum,  a 
species  of  regeneration  resulting  in  the  development  of  a  new  surface 
on  which  the  ovum  may  implant  itself.  In  the  human  female  there 
is  no  longer  this  regular  breeding  period,  but  desire  and  the  possibility 
of  impregnation  occur  at  irregular  periods  all  the  year  round.    In  the 


'•'■^V^Sf.-,* 


•»&»•#« -i-;S,?>V  t-ViiSSCj 


Fig.  7. — Ovarian  Ovum  of  a  Mammifer  (Allen  Thomson),  a.,  the  entire  ovum, 
viewed  under  pressiire;  the  granular  cells  have  been  removed  within;  b.,  the  exter- 
nal evat  or  zona  burst  by  increased  pressure,  the  yolk  protoplasm  and  the  germinal 
vesicle  having  escaped  from  within;  c,  germinal  vesicle  freed  from  the  yolk  sub- 
stance. 

human  subject  the  monthly  regeneration  and  preparation  of  the  endo- 
metrium are  for  the  same  purpose. 

In  the  lower  mammals  ovulation  takes  place  during  estrus  or  in 
pro-estrum,  and  in  most  animals  fertilization  of  the  ova  occurs  at  this 
time.  It  is  quite  possible  that  as  there  is  no  fixed  period  corresponding 
to  "heat"  in  the  human  subject  a  considerable  delay  may  occur  between 
insemination  and  ovulation  on  the  one  hand,  and  between  insemination 
and  fertilization,  or  the  actual  union  of  the  male  and  female  elements, 
on  the  other  hand.  But  it  seems  reasonable  to  suppose  that  the  most 
favorable  condition  for  successful  impregnation  lies  in  the  simul- 
taneous occurrence  of  insemination  and  ovulation,  or  at  least  at  no 
great  length  of  time  from  it,  and  the  fertilization  occurs  immediately 
on  the  meeting  of  the  two  elements,  just  as  is  the  case  in  the  lower 
animals.  In  conjuntion  with  each  ovary  there  is  an  oviduct,  the  fal- 
lopian tube,  opening  into  the  uterine  cavity  at  one  end  and  into  the 
peritoneal  cavity  in  the  immediate  vicinity  of  the  ovary  at  the  other. 


DEVELOPMENT  OF  THE  FEMALE  CELL  27 

At  the  distal  end,  encircling  its  opening,  is  a  fringe-like  process — the 
fimbriae.  These  fimbriae,  when  expanded,  are  supposed  to  aid  in  direct- 
ing the  ovum  into  the  tube.  The  tubes  are  about  four  inches  in  length 
and  continuous  with  the  superior  portion  of  the  uterine  cavity.  The 
tubes  are  covered  by  a  serous  coat,  reflected  from  the  peritoneum  lining 
the  abdominal  cavity,  are  composed  of  muscular  fibers  and  are  lined 
with  ciliated  epithelial  cells.  In  many  of  the  lower  mammals  a  single 
uterus  is  wanting,  but  is  represented  by  two  expanded  tubes  which 
take  its  place. 

LITERATURE 

Chipman,  W.  W.  Conservation  of  the  Ovary,  Trans.  Am.  Gyn. 
Soc.  191 1. 

Danforth,  C.  H.  Germ  Cells  Subject  to  Selection  on  the  Basis 
of  Genetic  Potentialities,  Jan.  Exp.  Zool.    Vol.  28,  No.  3.     1919. 

FiRKET.  Origin  of  Germ  Cells  in  the  Higher  Vertebrates,  Ant. 
Rev.    April  20,  1920. 

OCHOTERENA  AND  Ramiez.    EndocHnology.    Oct.  1920. 

ScHOCKET,  S.    Physiology  of  Ovulation,  S.  G.  &  O.    Aug.,  1920. 


CHAPTER  IV 

METHODS  OF  REPRODUCTION 

Protozoal  methods  of  reproduction — Formation  of  the  zyote — Morphological  and 
physiological  differences  between  the  ova  and  spermatozoa — Mitototic  cell 
division — Early  ideas  of  fertilization — The  span  of  life  of  a  spermatozoon — 
Definite  sexual  attraction — ^Union  between  germ  cells. 

When  the  ovum  has  been  expelled  by  the  rupture  of  the  graafian 
follicle,  it  is  received  on,  or  into,  the  fimbriated  end  of  the  fallopian 
tube.  The  fimbriae  are  covered  by  a  layer  of  ciliated  epithelium  con- 
tinuous with  the  ciliated  epithelium  lining  the  tube,  and  the  action  of 
the  cilia  wafts  the  ovum  into  and  along  the  tube  in  the  direction  of  the 
uterine  cavity.  At  any  point  in  its  passage  along  the  tube  where  it 
meets  the  spermatozoa,  fertilization  may  occur.  It  is  possible  for  the 
fertilization  to  take  place  in  the  ovary  if  the  ovum  is  not  expelled  when 
the  follicle  ruptures,  or  on  the  fimbriated  end  of  the  tube,  or  even  in 
the  cavity  of  the  uterus,  but  as  a  rule  it  happens  in  the  tube. 

Fertilization  may  occur  at  any  time  during  the  intermenstrual 
interval,  and  imbedding  take  place,  either  in  the  period  of  quiescence, 
or  in  the  period  during  which,  without  the  occurrence  of  pregnancy, 
the  premenstrual  and  menstrual  changes  would  have  been  progressing. 

The  result  of  our  seriation  of  these  early  cases  is  not  consistent 
with  the  older  views  regarding  menstruation  and  its  relations  to 
imbedding,  for  it  carries  with  it  the  conclusions  that  the  menstrual 
decidua  is  not  a  preparation  for  the  reception  of  an  ovum ;  that  men- 
struation is  not  an  abortion  of  an  unfertilized  ovum ;  and  that  ovula- 
tion does  not  necessarily  coincide  with  menstruation. 

Protozoal  Reproductivity. — The  method  of  reproduction 
which  results  in  the  formation  of  new  individuals  is  by  division.  This 
is  most  frequently  preceded  by  a  conjugation  in  the  protozoa,  or  by 
fertilization  in  both  protozoa  and  metazoa.  In  the  protozoa  there  are 
three  principal  methods  of  reproduction: 

I.  The  division  of  the  individual  takes  place,  resulting  in  the  for- 
mation of  two  parts  exactly  similar  in  size  and  structure,  but  smaller 

28 


METHODS  OF  REPRODUCTION  29 

in  size  than  the  original  parent  body.     These,  however,  eventually 
enlarge  to  form  cells  of  corresponding  size  to  the  parent  cell. 

2.  A  small  outgrowth,  or,  as  it  is  frequently  called,  the  bud, 
develops  on  the  parent  cell,  from  which  it  eventually  separates. 

3.  Many  daughter  nuclei  arise  from  the  division  of  the  nucleus  in 
the  parent  cell.  The  metazoa  reproduce  their  kind  either  sexually  or 
asexually.  When  asexual  reproduction  occurs,  the  process  takes  place 
without  the  aid  of  sex  cells,  as  is  instanced  by  many  polyps,  sponges, 
and  flat  worms.  Where  the  reproduction  is  sexual,  it  is  necessary  that 
the  individual  develop  from  a  mature  ovum.  In  nearly  every  instance 
the  ovum  has  to  be  fertilized  by  conjugation  with  a  spermatozoon. 

Formation  of  the  Zyote. — When  the  zyote  is  formed,  the  ova 
of  quite  a  large  number  of  animals  develop  without  this  fertilization. 
The  size  of  an  animal  is  determined  by  the  kind  of  sex  cell  it  produces, 
that  is  to  say,  the  ova  by  the  female  and  the  spermatozoa  by  the  male. 
But  in  quite  a  large  number  of  species  is  found  but  a  single  sort  of 
individual  which  produces  both  ova  and  spermatozoa.  These  are  the 
so-called  hermaphroditic  forms. 

Morphological  and  Physiological  Differences. — There  is  a 
wide  morphological  and  physiological  difference  between  ova  and 
spermatozoa.  As  a  rule,  ova  are  oval  in  shape  and  vary  greatly  in 
size.  In  the  mouse  they  are  only  about  0.065  ^^-  ^^  diameter,  running 
all  the  way  from  this  up  to  a  maximum  of  several  inches  in  length,  as 


Fig.  8. — Ovum  of  the  Cat;  Highly  Magnified.  Semi-Diagrammatic  (Quain).  zp., 
zona  pellucida,  showing  radiated  structure;  vi,  vitellus,  round  which  a  delicate 
membrane  is  seen;  gv.,  germinal  vesicle,  gs,  germinal  spot. 

found  in  some  birds.  In  the  early  study  of  the  ova  it  was  supposed 
that  the  ovum  as  a  whole  took  part  in  the  development  of  the  indi- 
vidual, but  later  the  nucleus  was  identified  as  the  true  germinal  vesicle. 


30  STERILITY  AND  CONCEPTION 

In  the  study  of  the  male  sex  cells,  or  spermatozoa,  is  found  a  very- 
different  formation.  These  are  composed  of  a  head,  a  middle  piece, 
and  a  vibratile  tail.  They  are  usually  of  the  flagellate  type.  Spermato- 
zoa are  minute  in  size,  varying  from  something  less  than  0.02  mm.  to 
2.0  mm.  According  to  Wilson,  it  would  take  from  400,000  to  500,000 
sea  urchin  spermatozoa  to  equal  in  volume  the  ovum  of  the  same 
species.  Thus  it  is  not  surprising  that  the  number  of  spermatozoa 
produced  by  a  single  male  may  be  many  hundred  thousand  times  as 
great  as  the  number  of  eggs  produced  by  the  female.  With  few  excep- 
tions the  eggs  lack  the  power  of  locomotion.  The  spermatozoa,  on  the 
other  hand,  are  active  motile  organisms,  propelling  themselves  by  the 
flagellate  action  of  their  tails  hither  and  thither  in  their  search  for  the 
passive  ova  which  they  are  to  fertilize.  As  a  rule,  only  one  spermato- 
zoon is  necessary  for  the  act  of  fertilization,  so  that  but  very  few 
fulfill  their  destiny.  The  enormous  horde  of  these  is  in  all  probability 
not  a  waste  on  the  part  of  nature,  but  is  to  make  more  certain  the  fer- 
tilization of  the  ova. 

In  nearly  all  species,  fertilization  must  take  place  before  the  ova 
can  develop,  and  by  fertilization  we  understand  the  fusion  that  takes 
place  between  an  ovum  and  a  spermatozoon  with  the  re-arrangement 
of  the  contents  of  the  fertilized  cell  that  results. 

As  has  been  stated,  it  is  common  for  only  one  spermatozoon  to 
enter  the  ovum,  but  there  are  a  few  examples  found  among  certain 
insects,  birds,  and  reptiles,  where  more  than  one  spermatozoon  enters 
and  fuses  with  the  ova.  In  some  instances  the  entire  corpus  of  the 
spermatozoon,  the  head,  the  middle  piece,  and  tail,  may  become  com- 
pletely imbedded  within  the  ovum.  The  tail  is,  as  a  rule,  left  outside, 
and  in  certain  few  cases  the  head  alone  enters  the  substance  of  the 
ovum. 

Mitotic  Cell  Division. — Wilson  in  "The  Cell  in  Development 
and  Inheritance"  says :  "In  mitotic  cell  division  we  have  become 
acquainted  with  the  means  by  which,  in  all  higher  forms  at  least,  not 
only  the  continuity  of  life,  but  also  the  maintenance  of  species,  is 
effected;  for  through  this  beautiful  mechanism,  the  cell  hands  on  to 
its  descendants  an  exact  duplicate  idioplasm  by  which  its  own  organism 
is  determined.  Fertilization,  or  fecundation,  is  the  essence  of  sexual 
reproduction,  and  in  it  we  behold  a  process  by  which,  on  the  one  hand, 
the  energ>'  of  the  cell  division  is  restored,  and  by  which,  on  the  other 
hand,  two  independent  lines  of  descent  are  blended  into  one." 


METHODS  OF  REPRODUCTION  31 

Early  Ideas  of  Fertilization. — Fertilization  was  regarded  by 
many  of  the  early  embryologists  as  a  certain  kind  of  stimulus  con- 
tributed by  the  spermatozoa,  and  by  means  of  which  the  Ovum  was 
animated  and  rendered  capable  of  development.  This  subject  is  one 
of  fascinating  interest,  but  to  enter  into  a  detailed  consideration  of  the 
innumerable  ways  in  which  germ  cells  are  brought  together  would 
carry  us  into  byways  leading  far  afield  from  the  intended  scope  of 
this  work.  It  should  be  borne  in  mind  that  according  to  the  species 
the  conjugation  between  the  cells  may  take  place,  either  inside  or  out- 
side the  body  of  the  mother.  When  the  union  is  accomplished  outside 
the  mother,  both  spermatozoa  and  eggs  are  discharged  into  a  common 
medium  in  which  fertilization  and  further  development  of  the  cells 
take  place. 


Fig.  9. — Ovum  of  Rabbit  from  the  Fallopian  Tube,  Twelve  Hours  after  Impreg- 
nation. (BiRCHOFF.)  Over  the  zona  a,  spermatozoa  are  seen,  and  others  in  the 
perioitellim  space;  b,  polar  globules. 

Spermatozoal  Life. — The  span  of  life  of  a  spermatozoon  is 
difficult  to  determine,  but  it  is  known  that  they  may  exist  for  a  very 
long  period  of  time  without  losing  their  fertility.  Their  active  motile 
life  begins  with  their  discharge,  and  is  comparatively  short.  Many 
examples  are  found  where  the  spermatozoa  are  inert  when  first  dis- 
charged and  do  not  become  motile  until  after  entering  into  contact 
with  the  medium  in  which  they  are  deposited. 

Sexual  Attraction. — The  question  of  a  definite  sexual  attrac- 
tion between  germ  cells  is  one  of  absorbing  interest,  and  in  some  cases 
a  very  positive  attraction  is  seen  to  exist.  If  the  spermatozoa  and  ova 
of  one  of  these  species  be  mixed  together  and  succeeding  events  care- 
fully watched,  it  will  be  seen  that  in  a  short  time  each  ovum  is  sur- 
rounded by  enveloping  spermatozoa,  which  cling  to  its  periphery  by 
their  heads,  and  by  the  violent  flagellate  movement  of  their  tails 
actually  produce  changes  in  the  position  of  the  ovum. 

While  the  exact  nature  of  this  attraction  is  not  known,  it  would 
seem,  according  to  the  investigations  of  Pfeffer  carried  out  on  the 


32  STERILITY  AND  CONCEPTION 

spermatozoids  of  plants,  to  be  of  a  chemical  nature,  and  experiments 
conducted  in  accordance  with  this  theory  point  strongly  to  a  specific 
chemical  substance  as  being  the  basis  of  attraction  between  germ  cells 
of  the  same  species.  It  seems  to  be  quite  clear  that  it  is  not  the  nucleus 
of  the  ovum  alone  that  exerts  the  attractive  force,  but  that  a  large  part 
is  played  by  the  cytoplasm  of  the  ovum,  for  the  Hertwigs  and  others 
have  demonstrated  the  fact  that  spermatozoa  will  quite  readily  enter 
a  fragment  of  the  ovum  which  does  not  contain  any  nucleus  whatso- 
ever. 

Union  of  Cells. — After  the  union  between  the  germ  cells  has 
taken  place,  many  wonderful  changes  occur  in  both.  Almost  as  soon 
as  penetration  is  accomplished,  the  movements  of  the  tail  cease. 
Occasionally  it  may  actually  enter  with  the  rest  of  the  organism,  but 
in  most  instances,  it  is  left  behind  and  remains  inert  on  the  outside. 
Even  when  it  enters  the  ovum,  it  promptly  degenerates  and  plays  no 
part  in  the  process  of  fertilization. 

The  effect  produced  on  the  ovum  by  the  entrance  of  the  spermato- 
zoon is  most  startling.  In  every  part  of  its  being,  marvelous  changes 
may  be  observed  to  take  place.  The  vitelline  membrane,  by  the  very 
rapidity  of  its  formation,  shows  that  the  stimulus  derived  by  fertiliza- 
tion spreads  with  the  greatest  rapidity  throughout  the  entire  ovum. 
The  ovum  may  now  even  show  marked  ameboid  movements,  contract- 
ing and  changing  its  form  in  many  different  ways.  A  new  life  has 
come  into  its  beginning  and  is  now  well  under  way. 

LITERATURE 

FouLis,  J.     Development  and  Structure  in  Man  and  Mammalia. 

1875- 

Oliver,     Early  Relationship  of  Oosperm  to  the  Endometrium, 

N.  Y.  Med.  Journal,  Sept.,  1908. 

Ritchie,  J.     Physiology  and  Pathology.     191 3. 

Wilson,  E.  B.    The  Cell  in  Development  and  Inheritance.     1900. 


CHAPTER  V 

GROWTH    OF   THE   FERTILIZED   CELL 

The  imbedding  of  the  human  ovum — Survival  of  the  fittest — Seasonal  influence  and 
breeding — Menstruation  and  periodicity. 


IMBEDDING  OF  THE  OVUM 

The  study  of  the  process  by  which  the  imbedding  of  the  human 
OA'um  is  accomplished  is  one  of  captivating  interest.  It  has  been  so 
well  described  by  Bryce  and  Teacher  that  I  cannot  do  better  than  give 
in  extcnso  their  unsurpassed  description  of  this  marvel  of  nature. 

"The  ovum  having  attained  the  stage  of  an  early  blastocyst,  meas- 
uring about  2  mm.  in  diameter  (i.e.,  approximately  the  size  of  the 


Q — m.jjn 


m.jyr.    '"{i:;-^:/':'::^:'^'<;'\'' 


/•!"• 


^.pr. 


Fig.  10. — Fertilization  of  the  Ovum  of  an  Echinoderm  (Selenka).  s.,  sperma- 
tozoon; m.pr.  male  pronucleus;  f.pr.,  female  pronucleus,  i.  accession  of  a  sper- 
matozoon to  the  periphery  of  the  vitellus;  2.  Its  penetration  and  the  radial  dis- 
position of  the  vitelline  granules;  3.  Transformation  of  the  head  of  the  spermato- 
zoon into  the  male  pronucleus;  4,  5.  Blending  of  the  male  and  female  pronuclei. 

mature  blastocyst),  comes  to  rest  in  a  slight  depression;  but  neither 
a  crypt  nor  a  fissure  in  the  endometrium  destroys  the  surface  epi- 
thelium, and,  continuing  its  destructive  activity,  passes  into  a  space  in 
the  decidua  which  has  been  thus  produced.  Necrosis  followed  by  solu- 
tion (digestion)  of  a  considerable  mass  of  the  endometrium  follows, 

33 


34  STERILITY  AND  CONCEPTION 

resulting  in  a  formation  of  an  implantation  cavity.  Changes  leading 
to  the  production  of  decidua  begin  immediately  after  the  solution  of 
the  epithelium,  and  the  elevation  is  formed  which  is  the  characteristic 
resting  place  of  all  the  four  earliest  ova  at  present  known. 

"The  mouth  of  the  implantation  chamber  is  probably  blocked  by  a 
mass  of  blood  clot,  the  cavity  having  meantime  been  filled  by  blood 
shed  from  the  opened-up  maternal  capillaries. 

"The  ovum,  now  rapidly  differentiating,  develops  a  thick  tropho- 
blast  all  around  the  blastocyst.  The  ovum  is  at  first  fr^e  in  the 
implantation  cavity.  The  trophoblast  from  a  very  early  stage  shows 
a  cellular  layer  and  a  plasmodial  layer.  The  plasmodium  throws  out 
buds  which  stretch  towards  the  walls  of  the  decidual  chamber  and  it  is 
continually  being  added  to  by  active  proliferation  in  the  cellular  layer. 

"In  the  first  place,  the  plasmodial  masses  exert  mainly  a  destructive 
action ;  this  results  in  the  production  of  a  relatively  larger  implantation 
cavity.  The  destruction  of  the  decidua  is  necessarily  associated  with 
the  destruction  of  vessel  walls  and  the  opening  up  of  glands.  Hemor- 
rhage occurs  with  the  cavity,  but  the  blood  does  not  coagulate.  It 
serves  to  nourish  the  ovum,  and  after  a  time  it  begins  to  circulate 
among  the  trophoblastic  processes.  Up  to  this  stage  the  ovum  has  not 
become  attached  to  the  decidua.  It  now  becomes  fixed,  first  by 
anchoring  strands  of  plasmodium  and  later  by  development  of  prim- 
itive cellular  villi.  In  the  further  changes  the  greater  part  of  the 
early  plasmodium  disappears  after  being  spun  out  into  fine  threads, 
while  the  marginal  cells  of  the  cytotrophoblastic  columns  continue  to 
form  new  plasmodium.  On  the  other  hand,  the  plasmodium  may  in 
part  persist,  the  strands  arranging  themselves  over  the  cytoblast  col- 
umns as  an  endotheliumlike  layer,  while  the  outlying  parts  remain  as 
the  irregular  masses  invading  the  decidua.  It  appears  probable  that 
the  extensive  plasmodium  is  in  great  part  a  temporary  formation  pro- 
vided for  the  early  enlargement  of  the  implantation  cavity.  The 
attachment  of  the  ovum  is  effected  when  the  columns  of  cytotropho- 
blast  reach  the  decidua  at  points  from  which  the  necrotic  layer  has 
been  removed,  and  become  fixed  by  the  terminal  cells  insinuating  them- 
selves among  the  elements  of  the  decidua." 

As  Wilson  says:  "We  thus  find  the  essential  fact  of  fertilization 
and  sexual  reproduction  to  be  a  union  of  equivalent  nuclei,  and  to  this 
all  other  processes  are  tributary.  From  the  mother  comes,  in  the  main, 
the  cytoplasm  of  the  embryonic  body  which  is  the  principal  stratum  of 
growth  and  differentiation.     From  both  parents  comes  the  hereditary 


GROWTH   OF  THE   FERTILIZED   CELL  35 

basis  or  chromatin  by  which  these  processes  are  controlled,  and  from 
which  they  receive  the  specific  stamp  of  the  race." 

Man,  in  common  with  all  other  animals,  inherits  his  personal  char- 
acteristics both  bodily  and  mental  from  his  parents,  and  the  acquisition 
of  these  dates  back  to  the  original  fusion  between  the  two  parent  cells, 
the  ovum  and  the  spermatozoon. 

After  the  development  of  the  embryo  to  maturity  and  its  final 
expulsion  from  the  uterus,  it  begins  what  may  be  designated  as  its 
individual  existence.  Certain  fixed  laws  govern  its  further  activity, 
dependent  upon  three  great  causes:    heredity,  training,  and  environ- 


FiG.  II. — Human  Spermatozoa  (Williams),    h.,  head;   c,  intermediate  portion;   t., 

tail. 

ment.  During  the  rest  of  life,  while  environment  and  training  may 
and  at  times,  do  exert  a  very  strong  influence,  heredity  is  always  the 
most  potential  and  all-powerful  determining  factor  in  the  conduct  of 
the  individual. 

In  the  great  struggle  for  existence,  various  factors  make  for  the 
survival  of  the  fitter.  Physical  strength  is  a  most  important  factor; 
some  survive  solely  because  they  are  strong,  while  others  owe  their 
survival  to  cleverness;  some  are  agile  above  their  fellows,  and  in  this 
way  escape  the  dangers  that  lead  to  extermination;  while  still  others 
survive  because  they  are  able  to  put  on  a  garment  of  invisibility  that 
hides  them  from  their  enemies. 

Punnett  has  made  some  very  interesting  calculations  in  this  regard. 
He  has  estimated  that  if  in  a  population  of  ten  thousand  wild  animals, 
there  were  only  ten  of  a  new  and  promising  species,  and  that  these 
had  only  a  five  per  cent  selective  advantage  over  the  original  forms, 
they  would  predominate  in  less  than  one  hundred  generations  and  the 


36  .  STERILITY  AND  CONCEPTION 

older  variety  would  almost  completely  disappear.  There  are  many 
instances  known  of  such  replacements  occurring  in  primitive  nature, 
and  it  is  quite  evident  that  the  rate  of  replacement  of  the  old  by  the 
new  would  depend  in  great  part  on  the  fertility  of  the  new.  It  has 
many  times  been  observed  that  an  intense  elimination  of  individuals, 
unaccompanied  by  life-saving  peculiarities  or  variations,  will  move  a 
species  in  a  certain  direction  which  is  known  as  lethal  selection,  but  it 
is  likewise  plain  that  variants  that  possess  some  valuable  life-saving 
quality  will  predominate  with  greater  rapidity  if  they  are  at  the  same 
time  more  prolific  than  their  neighbors,  and  such  instances  are  known 
as  reproductive  selection. 

If  only  a  casual  review  of  plant  and  animal  life  be  made,  we  are 
at  once  impressed  with  the  fact  that  they  are  extraordinarily  fertile 
and  it  would  appear  oftentimes  extravagantly  so.  It  has  been 
estimated  that  if  all  the  progeny  of  but  one  oyster  survived  and  multi- 
plied "its  great,  great,  great,  grand  offspring  would  number  sixty-six 
with  thirty-three  noughts  after  it  and  the  heap  of  shells  would  be 
eight  times  the  size  of  our  earth." 

When  a  family  reaches  into  the  thousands  or  millions,  there  is  a 
wide  margin  to  allow  for  accidents,  so  that  careful  nursing  is  of  minor 
importance;  and  in  the  lower  forms  of  life,  where  parent  rearing  of 
such  offspring  is  impossible,  the  spawning  method  has  obvious 
advantages.  From  the  point  of  view  of  the  parent  advantage,  there 
are  manifest  disadvantages  inherent  in  this  method.  Multitudinous 
production  often  causes  the  exhaustion  and  even  the  death  of  the 
mother,  as  is  instanced  not  only  in  the  delicate  butterfly,  but  in  the 
strong  marine  lamprey,  where  she  dies  in  the  process  of  reproduction. 

There  is  an  old-world  type,  the  peripatus,  that,  although  having  no 
armor  nor  weapons  for  offense  or  defense,  has  held  its  own  in  many 
parts  of  the  world  for  millions  of  years.  It  has  been  able  to  do  thi^ 
because  of  its  nocturnal  and  elusive  habits,  and  because  its  young  are 
carried  by  the  mother  for  a  long  time  before  birth,  and  when  finally 
born  appear  as  miniature  adults,  ready  at  once  to  provide  for  them- 
selves. 

Almost  all  animals,  with  the  exception  of  man,  have  a  regular 
breeding  season  which  is  devoted  to  the  propagation  of  their  species. 
This  period  of  sexual  activity  is  to  a  considerable  extent  modified  by 
climatic  conditions  and  environment,  any  marked  change  in  the  life 
habits  of  an  animal,  as  Darwin  has  shown,  tends  to  affect  its  powers  of 
reproduction,  and  many  animals  breed  poorly,  or  not  at  all,  in  cap- 


GROWTH  OF  THE  FERTILIZED  CELL  37 

tivity.  The  term  sexual  season  is  used  to  designate  the  period,  or 
periods,  when  the  sex  organs  show  a  special  characteristic  activity,  and 
the  individual  is  capable  of  copulation.  In  many  species  the  male  is 
not  limited  in  this  respect,  being  able  to  serve  at  any  time,  while  the 
female  is  restricted  to  definite  periods  of  reception.  When,  as  a  result 
of  the  coming  together  of  the  sexes,  impregnation  occurs,  it  is  followed 
by  a  period  of  gestation,  varying  in  length  according  to  the  species. 
This  in  turn  is  followed  by  delivery,  then  comes  a  short  period  of 
recovery,  the  puerperium,  and  a  longer  period  of  nursing  or  lactation. 

Seasonal  Influence  and  Breeding. — While  in  the  lower  animals 
the  sexual  season  is  usually  limited,  and  occurs  rhythmically,  this  rule 
does  not  hold  as  the  scale  of  life  ascends.  There  is  a  marked  similarity 
between  the  sexual  season  in  the  lower  animals  and  the  period  of 
menstruation  in  the  higher  mammalia.  The  female  monkey,  as  well  as 
the  human  female,  has  a  continuous  series  of  diestrous  cycles  at 
monthly  intervals,  but  is  not  capable  of  impregnation  at  every  one. 
Unlike  the  majority  of  mammals,  monkeys  occasionally  copulate  at 
other  times  than  the  regular  breeding  season. 

Periodicity  of  Menstruation. — In  the  human  female,  from 
puberty  to  the  climacteric,  menstruation  recurs  monthly  at  intervals  of 
from  twenty-eight  to  thirty  days.  Numerous  exceptions  to  this  rule 
occur,  and  there  may  be  long  intervals  between  the  periods,  or  men- 
struation may  come  as  often  as  every  two  weeks.  Climatic  conditions 
exert  a  very  marked  influence  on  menstruation,  it  being  more  frequent 
and  regular  in  warm  climates  than  in  cold,  while  its  regularity  is  often 
disturbed  by  changes  of  environment,  such  as  change  of  residence  and 
foreign  travel  when  a  temporary  cessation  for  several  months  is  often 
observed. 

While  it  would  seem  from  the  evidence  thus  far  gathered  that 
primitive  woman,  in  common  with  the  lower  primates,  may  have  a 
definite  sexual  season,  it  is  doubtful  if  civilized  woman  is  subject  to 
any  such  restrictions. 

LITERATURE 

Handler,  S.  W.  Relation  of  Ovary  to  Normal  and  Pathological 
States.     1901. 

Bland-Sutton,    loc.  cit. 

Bryce  and  Teacher.  Early  Development  and  Embedding  of 
the  Ovum.     1908. 


'38  STERILITY  AND  CONCEPTION 

Frank.    Function  of  the  Ovary,  S.  G.  &  O.    191 1. 
Heape^  W.     Text-book  of  Embryology.     19 14. 
Jones.     Studies  in  the  Normal  and  Pathological  Structures  of  the 
Ovary,  Am.  Gyn.  and  Ped.  Oct.,  1901. 
LoEB,  L.    Germ  Cells,  Am.  Nat.  191 5. 
Weissman,  a.    The  Germ-plasm.     1892. 


CHAPTER  VI 

DEFINITION  AND  CLASSIFICATION 

Definition  of  fertility — Race  and  fertility — Duration  of  Fertility — Definition  of 
Sterility — Sterility  classified — Case  report  on  sterility — Predisposing  factors  of 
sterility. 

FERTILITY 

The  fertility  of  a  people  depends  to  a  greater  or  less  degree  upon 
many  outside  influences,  the  more  common  of  which  have  been  con- 
sidered in  a  previous  chapter.  The  duration  of  woman's  reproductive 
period,  while  it  begins  earlier  than  that  of  man's,  is  not  as  prolonged 
and  has  a  definite  ending — the  climacteric.  With  man  there  is  no 
definite  ending,  and  he  often  retains  his  fertility  to  an  advanced  age. 
Woman's  fertile  period  starts  at  puberty  and  gradually  increases  up 
to  about  the  age  of  thirty,  after  this  it  begins  to  decline.  Her  age  of 
greatest  fertility  is  between  twenty  and  thirty. 

Race  and  Fertility. — It  is  undoubtedly  true  that  fertility  is  to 
a  great  extent  a  racial  characteristic,  capable  of  hereditary  transmis- 
sion, and  it  has  been  clearly  shown  that  woman  may  inherit  a  high 
degree  of  fertility  from  either  the  paternal  or  maternal  side  of  her 
family.  When  once  the  rate  of  fertility  has  begun  to  decline,  it  is 
rarely  if  ever  raised  in  succeeding  generations. 

Definition  of  Sterility. — When  we  endeavor  to  find  a  satisfac- 
tory definition  for  sterility,  we  are  met  at  the  outset  with  the  fact  that 
the  word  sterility  admits  of  various  interpretations  and  must  be  used 
in  quite  a  broad  sense.  While  it  is  true  that  in  the  ordinary  acceptance 
of  the  term,  sterility  implies  a  condition  in  which  the  woman  does  not 
conceive,  or  if  conception  occurs,  is  unable  to  bear  a  viable  and  living 
child,  there  is  a  very  wide  difference  between  incapability  of  conception 
and  incapability  of  reproduction.  If  a  woman  cannot  reproduce  her 
kind,  the  fact  that  she  may  be  able  to  conceive  is  of  minor  importance. 

Classification  of  Sterility. — We  thus  see  at  once  the  necessity 

39 


40  STERILITY  AND  CONCEPTION 

for  establishing  different  classes  of  sterility  before  a  systematic  con- 
sideration of  the  subject  can  be  undertaken.  While  it  may  be  helpful 
for  the  purpose  of  clinical  study  to  divide  all  cases  of  sterility  into  two 
classes,  absolute  sterility  and  relative  sterility,  these  become  at  times 
more  or  less  arbitrary  and  are  not  always  entirely  satisfactory.  Gen- 
erally speaking,  we  include  in  the  class  of  absolute  sterility  those  cases 
where  conception  has  never  occurred;  while  in  the  relative  class  are 
placed  those  where  conception  has  taken  place  but  has  resulted  in  the 
early  death  of  the  fetus,  or  in  the  birth  of  a  non-viable  child. 

To  these  divisions  into  absolute  and  relative  sterility,  a  third  sub- 
division of  conditional  sterility  may  be  added.  This  is  distinctly  an 
acquired  condition.  The  woman  may  have  given  birth  to  one  or  more 
living  children  at  normal  intervals  and  then  follows  a  protracted  period 
of  sterility.  The  following  detailed  definitions  of  sterility  are  prob- 
ably as  satisfactory  as  any  that  can  be  formulated : 

Primary  Sterility  denotes  that  a  woman,  while  living  with  a 
fertile  man  in  her  period  of  sexual  maturity,  has  yet  never  been  preg- 
nant. 

Secondary  sterility  indicates  those  cases  where  the  woman  has 
borne  one  or  more  children  and  becomes  sterile  thereafter. 

Congenital  sterility  includes  those  women  who,  from  the  very 
beginning  of  their  sexual  life  have  had  some  condition  responsible  for 
the  sterility. 

Acquired  sterility  implies  that  the  woman  was  originally 
potentially  fertile  but  later  contracted  some  condition  that  caused  her 
to  become  sterile.  This  division  includes  both  primary  and  secondary 
sterility. 

Apparent  sterility,  also  called  functional  sterility  and  potential 
sterility.  In  this  group  are  placed  those  women  who,  owing  to 
some  prohibiting  condition  of  their  married  life,  have  never  had  a 
proper  chance  to  become  pregnant. 

Absolute  sterility  exists  where  the  uterus,  tubes,  or  ovaries  are 
absent;  when  the  tubes  are  occluded,  preventing  the  passage  of  the 
spermatozoa  or  entrance  of  the  ovum;  when  the  ovaries  are  so  sur- 
rounded by  adhesions  as  to  prevent  the  ovum  from  gaining  access  to 
the  tube  or  have  their  cortex  so  thickened  as  to  prevent  the  liberation 
of  the  ovum.  Cases  coming  under  this  head  may  be  primary,  con- 
genital, or  acquired. 

Under  sex  incompatibility  will  have  to  be  included  all  cases  that  do 
not  properly  come  under  any  of  the  above  headings. 


DEFINITION  AND  CLASSIFICATION  41 

In  many  unions  coming  under  the  head  of  absolute  sterility,  the 
fault  lies  with  the  male,  the  rate  being  variously  estimated  at  from 
twenty  to  fifty  per  cent.  However,  the  question  of  the  male  does  not 
concern  us  here  save  to  emphasize  the  fact  that  his  fertility  should 
never  be  taken  for  granted.  Only  too  often  is  the  wife  unjustly 
blamed  for  what  is  not  in  the  least  her  fault,  no  examination  of  the 
husband  ever  having  been  made  to  determine  the  question  of  his  fer- 
tility. The  great  number  of  women  that  have  been  thus  accused  of 
sterility  and  even  subjected  to  unnecessary  operation  is  a  sad  chapter 
in  gynecology.  So  typical  of  this  was  the  following  case  that  I  give 
the  history  in  detail. 


Mr.s.  F.  A.  was  twenty-nine  years  old  and  had  never  suffered  any  serious  illness 
or  injury;  her  menstruation  had  always  been  regular  and  normal  in  every  way, 
but  though  married  for  seven  and  one-half  years,  she  had  never  been  pregnant. 
Frequent  examinations  had  been  made  by  leading  physicians  in  her  native  city  and 
an  exploratory  laparatomy  decided  upon  to  determine  and,  if  possible,  correct  the 
cause  of  her  sterility.  When  she  was  referred  to  me  for  this  operation,  an 
examination  made  after  intercourse  failed  to  show  the  presence  of  any  spermato- 
zoa whatsoever  in  her  genital  tract,  and  a  subsequent  interview  with  her  husband, 
who  said  he  had  never  been  examined  as  to  his  fertility,  disclosed  the  fact  that  only 
one  testicle  had  descended  into  his  scrotum  and  that  this  had  been  removed  for  a 
chronic  inflammation  some  years  before  marriage.  His  fertility  had  been  taken 
for  granted  on  the  totally  inadequate  testimony  that  he  was  able  to  cohabit  regularly. 


As  I  have  already  said,  it  is  not  my  intention  to  take  up  in  detail 
in  this  book  the  question  of  male  sterility.  This  subject  I  leave  to 
those  far  better  qualified.  Their  studies  have  led  to  a  somewhat  wide 
divergence  of  opinion  regarding  the  proportionate  responsibility  of 
the  man  in  childless  marriages  and  tend  to  show  that  it  varies  con- 
siderably in  different  social  states. 

Predisposing  Factors  in  Sterility. — For  instance  it  is  greater 
where  conditions  predispose  toward  impure  intercourse,  sexual  excess, 
self-abuse,  and  late  marriage,  as  exist  among  the  well-to-do,  than  it  is 
among  those  who  marry  early  and  lead  an  active,  healthy,  busy  life 
devoted  to  hard  physical  work.  There  are  various  ways  in  which  the 
man  may  be  at  fault.  The  testicles  may  contain  no  live  spermatozoa, 
or  if  live  spermatozoa  be  present,  pathological  changes  in  the  epi- 
didymis may  prevent  them  reaching  the  seminal  vesicles.  In  these 
cases,  the  semen  is  composed  of  prostatic  secretion  alone  and  is  devoid 
of  spermatozoa  (azoosperma).  In  other  cases,  the  semen  may  be 
normal,  but  the  man,  because  of  some  malformation  of  the  penis, 


42  STERILITY  AND  CONCEPTION 

stricture  of  the  urethra,  or  Inability  to  obtain  erection,  cannot  deposit 
it  in  the  vagina  (Impotence). 

From  now  on  in  this  work  I  shall  take  for  granted  that  the  fer- 
tility of  the  husband  has  been  demonstrated  beyond  all  reasonable 
doubt,  and  that  the  wife  has  had  a  proper  chance  of  becoming  preg- 
nant. 


CHAPTER  VII 

ETIOLOGY 

Pathological  conditions  influencing  sterility — Germ  cell  retardation  and  racial 
poisons — Primitive  woman's  freedom  from  sterility — Etiology  of  sterility — 
Anatomical  errors  and  maldevelopment  —  Vaginismus  —  Dyspareunia  —  Case 
report  of  infantile  organs — Suspension  of  ovarian  activity — Menstrual  cessation 
through  shock,  obesity,  climatic  changes,  over  indulgence  in  sexual  intercourse, 
and  X-ray  exposure — Acquired  sterility,  absolute  or  relative — Germ  cell  injury 
through  parental  alcoholism — Social  factors  and  reproductivity — Frequent  child 
bearing  and  reproductivity — Incompatibility  as  a  factor  in  sterility. 

Pathological  Conditions  Influencing  Sterility. — There  are 
many  pathological  conditions  that  may  be  responsible  for  a  sterile 
union.  In  the  case  of  the  man,  sterility  may  be  due  to  an  inability 
to  perform  the  sexual  act,  or  to  an  actual  absence  of  semen  or 
fertile  spermatozoa.  The  former  may  be  the  result  of  want  of 
sexual  desire,  absence  of  the  power  of  erection  and  ejaculation, 
or  the  cause  may  be  anatomical,  pathological,  physiological,  or 
even  psychological.  Absolute  sterility  may  be  due  to  the  absence 
of  fertile  spermatozoa  and  can  be  either  congenital  or  acquired. 
Congenital  male  sterility  occurs  when  the  testicles  are  so  imper- 
fectly developed  that  they  do  not  supply  fertile  spermatozoa. 
Again,  sterility  may  be  caused  by  various  diseases  of  the  gen- 
erative organs,  and  also  from  constant  exposure  to  the  X-rays. 

Germ  Cell  Retardation. — The  germ  cells  during  their  develop- 
ment in  the  female  sex  glands  are  markedly  affected  by  racial 
poisons  such  as  alcohol  and  by  the  venereal  disease  syphilis. 
After  fertilization,  the  ovum  in  the  uterus  may  be  attacked  by 
syphilis,  or  its  future  life  interrupted  by  abortion.  When  the  fetus 
has  reached  a  viable  age,  prenatal  conditions,  racial  poisons,  and 
abortion  are  frequent  causes  of  death. 

Primitive  Woman's  Freedom  from  Sterility. — Among  prim- 
itive people,  woman  is  notoriously  free  from  many  of  the  steriliz- 

43 


44  STERILITY  AND  CONCEPTION 

ing  influences  to  which  her  sister  in  our  present-day  civilization,  is 
prone.  Departing  from  a  natural  and  adopting  an  unnatural  and 
artificial  mode  of  life,  we  find  that  Nature  exacts  due  penalties 
for  every  transgression  of  her  laws.  The  female  among  savage 
tribes  has  every  advantage  and  opportunity  to  develop  physical 
perfection,  and  her  strength  and  endurance  suffer  little  by  com- 
parison with  the  male.  How  different  in  our  modern  system  of 
society ! 

Etiology  of  Sterility. — In  considering  the  various  and  varied 
causes  of  sterility  I  shall  attempt  no  systematic  classification,  or 
even  enumeration  of  all  the  possible  causes,  for  I  feel  that  such 
would  lead  to  much  repetition  and  little  profit.  While  a  patho- 
logical classification  is  interesting,  and  at  times  necessary,  a 
broader  clinical  arrangement  is  more  valuable  for  study,  and  more 
in  keeping  with  a  monograph  of  this  character. 

Anatomical  Errors  and  Maldevelopment. — From  an  anatom- 
ical standpoint,  errors  in  development  and  lack  of  development  of 
the  genital  passages  and  organs  may  play  an  important  part  in 
sterility.  Such  maldevelopment  may  actually  prohibit  intercourse, 
as  in  absence  of  the  vagina;  or  prevent  conception,  as  when  the 
uterus,  ovaries,  or  tubes  are  missing.  Absence  of  the  vagina  is 
rare  and  when  present  is  always  associated  with  an  undeveloped 
condition  of  the  uterus  and  ovaries,  and  such  cases  offer  no  hope 
of  a  cure  from  the  viewpoint  of  sterility.  Atresia  of  the  vagina  is 
a  more  common  condition  and  occurs  when  the  fusion  of  the  ducts 
of  Miiller  fails  to  reach  the  surface.  The  existing  barrier  is  an 
obstructing  membrane  that  lies  just  above  the  hymen  and  this 
can  be  easily  divided,  thus  establishing  the  patency  of  the  vagina. 
Occasionally  cases  are  met  where  the  vagina  is  congenitally  too 
narrow  to  admit  of  intercourse  (stenosis)  or  so  constricted  in  its 
middle  third  (hour-glass  contraction)  as  to  render  proper  intercourse 
difficult.  An  abnormally  rigid  hymen  may  for  a  while  prevent  inter- 
course, but  its  resistance  is  usually  eventually  overcome  and  it  does  not 
often  require  cutting. 

Coitus  may  be  rendered  impossible  by  nervous  spasm  of  the 
muscles  at  the  vaginal  orifice  and  of  the  leg  muscles  (vaginismus), 
which  is  excited  by  the  slightest  approach  on  the  part  of  the  male,  or  it 
may  be  rendered  so  extremely  painful  by  some  lesion  of  the  genital 
passage  or  genital  organs  that  after  one  attempt  it  is  very  seldom 
repeated  (dyspareunia).     On  the  other  hand,  there  may  be  various 


ETIOLOGY  45 

errors  in  development  of  the  genital  tract  that,  while  they  do  not  offer 
any  obstacle  to  proper  intercourse,  yet  are  a  cause  of  sterility.  Such 
are  absence  of  the  uterus,  fallopian  tubes,  or  ovaries.  At  times  even 
though  not  actually  absent,  these  organs  may  be  so  underdeveloped 
or  maldeveloped  as  to  be  incompatible  with  conception.  The  so-called 
infantile  pelvic  organs  are  associated  with  a  very  high  degree  of  steril- 
ity, but  they  may  later  mature  and  the  woman  give  birth  to  one  or  more 
children. 

Mrs.  S.  M.,  twenty-six  years  old,  had  been  married  for  three  years.    She  had 
had  scarlet  fever  at  six  years  of  age  and  measles  twice,  at  twelve  and  sixteen  years 
respectively.     She  was  a  premature  and  only  child  of  her  mother 
and  weighed  but  one  and  one-fourth  pounds  at  birth  and  was 
never  particularly  well  or  robust  as  a  child.    Menstruation  began 
at  thirteen  years ;  was  regular,  lasting  seven  to  nine  days ;  mod- 
erate in  amount.     She  suffered  always   from  severe  dysmenor- 
rhea, backache,  nausea,  and  vomiting.    For  the  past  five  years  the 
dysmenorrhea  has  become  at  times  unbearable  and  she  has  had 
two  attacks  of  menstrual  mania.     Two  years  after  marriage,  the 
uterus  was  dilated  and  curetted,  which  slightly  relieved  the  men- 
strual pam  for  about  one  year.    The  dysmenorrhea  then  became 
as    severe    as    ever.      Examination :      Patient    short    of    stature. 
External  genitalia  undeveloped,  pubic  hair  deficient,  vagina  small 
Fig.  12. — Infan-      ^"d  short,  cervix  infantile  in  type,  its  vaginal  aspect  only  one- 
TILE    Uterus      half   inch   in   diameter.     Fundus    likewise    infantile   type,   being 
(Schroeder)  about  the  size  of  an  English  walnut.     The  combined  depth  of 

the  cervical  canal  and  uterine  cavity  measured  but  two  inches. 
In  this  case  an  unfavorable  prognosis  was  given  and  no  operative  treatment  ad- 
vised. Subsequent  to  this  examination  she  menstruated  normally  for  one  year 
without  the  slightest 'pain,  conceived  during  the  following  year  and  gave  birth  by 
normal  delivery  to  a  living  child  at  term.  Two  children  were  born  after  this 
without  any  return  of  her  old  menstrual  difficulty. 

Infantilism. — The  above  case  is  the  most  marked  example  of 
the  exception  to  the  rule  that  I  have  ever  encountered  in  infantile 
pelvic  organs.  Such  cases  are  rare  and  are  not  always  distinguished 
from  anteflexion  and  stenosis  of  the  cervical  canal  which  is  a  persist- 
ence, though  to  a  less  degree,  of  the  infantile  uterus  and  is  accom- 
panied by  a  much  higher  rate  of  fertility.  This  is  always  a  congenital 
condition  and  the  associated  lack  of  fertility  is  due  to  the  immaturity 
of  the  uterus  and  not  to  the  angle  of  flexion  of  the  cervix  or  the  cer- 
vical canal,  as  is  so  often  erroneously  taught. 

Absolute  sterility,  while  it  may  be  due  to  causes  already  mentioned, 
is  many  times  an  acquired  condition  produced  by  changes  that  either 


46  STERILITY  AND  CONCEPTION 

so  affect  the  function  of  the  ovaries  as  to  prevent  proper  ovulation  or 
destroy  the  transmitting  or  incubating  powers  of  the  genital  tract. 
Inflammatory  thickening  of  the  cortex  of  the  ovary  thus  preventing 
graafian  follicle  rupture  with  discharge  of  the  ovum,  and  infiammator^ 
occlusion  of  the  tubes  are  concrete  examples  of  this. 

Suspension  of  Ovarian  Activity. — That  ovarian  activity  may 
be  suspended  over  a  considerable  period  of  time  other  than  that  of 
pregnancy  and  lactation,  when  the  suppression  is  physiological,  is  well 
recognized.  There  is  undoubtedly  a  very  close  relationship  "between 
menstruation  and  ovulation  though  just  how  close  remains  as  yet  to  be 
decided,  for  menstruation  may  continue  regularly  in  the  absence  of 
ovulation  just  as  ovulation  may  take  place  when  menstruation  is  sup- 
pressed, as  instanced  by  the  many  cases  where  conception  takes  place 
during  lactation,  before  menstruation  has  been  re-established.  While 
suppression  of  ovarian  activity  for  a  comparatively  short  space  of  time 
is  occasionally  seen  in  certain  diseases,  such  as  anemia  and  the  severe 
exanthemata,  and  for  somewhat  longer  periods  in  tuberculosis, 
myxedema,  and  cretinism,  it  is  rare  to  find  prolonged  cessation  in 
women  enjoying  good  health.  The  longest  period  of  temporary  cessa- 
tion with  subsequent  conception  that  I  have  ever  met  with,  and  a  case 
which  is  a  very  good  example  of  the  close  relationship  existing  between 
menstruation  and  ovulation,  was  that  of  Mrs.  T.  S.,  cited  on  page  136. 

Shock. — Grave  mental  shock,  severe  nervous  strain,  and  serious, 
anxious  care  may  all  cause  a  temporary  cessation  of  menstruation,  but 
whether  they  likewise  suppress  ovulation  it  would  be  difficult  to 
determine.  The  sudden  death  of  a  near  and  dear  relative  can  produce 
a  premature  menopause,  and  I  have  seen  this  occur  in  comparatively 
young  women  at  times  as  early  as  the  thirty-fifth  year.  A  severe  post- 
partum infection  can  cause  a  long  period  of  temporary  sterility,  even 
when  there  has  been  no  accompanying  occlusion  of  the  tubes,  as  can 
also  an  aggravated  auto-intoxication  following  childbirth.  Prolonged 
lactation,  as  well  as  the  administration  of  large  doses  of  pituitrin  or 
ergot  after  labor,  may  produce  a  superinvolution  of  the  uterus,  leading 
to  a  long  period  of  sterility. 

Nutrition. — It  has  been  maintained  for  some  time  by  certain 
investigators  that  the  dietary  was  an  important  factor  in  sterility 
and  fertility,  and  that  certain  diets,  especially  those  rich  in  pro- 
teins, exerted  a  marked  beneficial  effect  on  reproduction  in  both 
quality  and  quantity.     McCallum,  Osborne  and  Mendal  have  pointed 


ETIOLOGY  47 

oiit  that  diets  lacking  in  the  mineral  salts,  especially  calcium,  and  in  a 
sufficient  amount  of  the  proteins,  produce  a  lowered  fertility. 

With  these  views  animal  breeders  have  long  been  in  accord,  and 
among  them  it  is  an  established  custom  to  give  rich  protein  diet  to 
favor  successful  reproduction.  Recently  Reynolds  and  Macomber 
have  carried  out  a  most  instructive  series  of  experiments  with  white 
rats  along  these  lines.  Their  investigations  show  that  dietary  deficien- 
cies carried  to  the  extent  even  to  produce  ill  health,  result  in  a  high 
percentage  of  infertile  matings;  that  many  of  these  victims  were 
incapable  of  reproduction  when  remated  with  highly  fertile  partners ; 
that  the  degrees  of  infertility  so  produced  could  be  estimated  with  a 
fair  degree  of  certainty,  and  that  it  was  possible  to  approximate  a 
threshold  of  fertility  below  which  reproduction  does  not  occur.  They 
drew  the  following  conclusions  from  their  laboratory  experiments: 

(i)  That  a  moderate  decrease  in  the  percentage  of  the  fat  soluble 
vitamine  of  the  protein  or  of  the  calcium  contained  in  an  otherwise 
excellent  diet  produces  a  definite  decrease  in  the  fertility  of  individual 
rats. 

(2)  That  a  slight  decrease  in  the  fertility  of  both  partners  will 
produce  a  sterile  mating. 

(3)  That  the  fertility  of  the  mating  may  be  stated  as  the  product 
of  the  fertility  of  the  individuals  concerned. 

(4)  That  if  the  index  so  obtained  falls  below  a  given  point  the 
matings  will  be  sterile,  and  that  this  result  holds  true  whether  the 
partners  are  of  equal  or  of  widely  different  fertility. 

(5)  That  these  principles  explain  the  fact  that  two  individuals 
which  are  sterile  when  mated  together  may  nevertheless  reproduce 
freely  when  mated  to  new  partners  (of  higher  fertility). 

(6)  That  dietary  deficiencies  produce  a  lowered  fertility  which 
varies  in  degree  with  different  individuals  though  of  the  same  parent- 
age and  in  the  same  cage. 

(7)  That  diminished  fertility  sometimes  results  in  the  appearance 
of  abortion. 

(8)  That  mere  percentage  deficiency  in  both  proteins  and  calcium 
produce  visible  ill  health  and  great  infertility. 

Obesity  — Obesity  is  a  condition  that  has  long,  even  since  the  time 
of  Hippocrates,  been  noted  as  having  a  very  direct  bearing  on  the  repro- 
ductive function.  Fat  women  are  not  as  fertile  as  their  thin  sisters. 
A  rapid  accumulation  of  fat  is  frequently  accompanied  by  an  absence 
of  menstruation,  flashes  of  heat  and  cold,  and  sterility,  all  symptoms  of 


48  STERILITY  AND  CONCEPTION 

a  cessation  of  ovarian  activity.  Oliver  says,  "I  have  frequently 
remarked  that  women  who  tend  to  lay  on  fat  rapidly  are  apt  to  become 
barren."  It  is  no  unusual  experience  to  find  such  women  enthusi- 
astically imagining  themselves  pregnant,  and  even  imbuing  their 
physician  with  an  equal  degree  of  enthusiasm  that  carries  them  both 
to  the  expected  date  of  confinement  before  the  error  is  discovered. 

Climatic  Changes. — Wide  change  of  climate  will  frequently 
produce  a  temporary  suspension  of  menstruation,  and  I  have  had  many 
women  under  my  care,  who,  on  coming  to  this  country  from -distant 
parts,  suffered  from  amenorrhea  for  a  number  of  months.  In  one 
patient  the  amenorrhea  lasted  for  eight  months  before  her  menstrua- 
tion reappeared.  Usually  acclimation  takes  place  in  a  few  months  and 
menstruation  then  continues  normally.  I  have  never  known  one  of 
these  patients  to  conceive  during  such  a  period  of  amenorrhea. 

Excessive  Coitus. — Over  indulgence  in  sexual  intercourse  is  gen- 
erally supposed  to  have  a  deleterious  effect  on  fertility,  and  my 
experience  leads  me  to  believe  that  such  is  the  fact.  In  such  cases,  if 
a  long  period  of  sexual  rest  is  practiced,  it  is  not  unusual  for  concep- 
tion to  occur  promptly  on  the  resumption  of  marital  relations. 

X-RAY  Exposures. — The  sterilizing  effect  of  the  X-ray  is  also  well 
recognized,  and  prolonged  and  repeated  exposures  result  in  atrophy 
of  the  ovaries,  with  a  corresponding  cessation  in  their  activity. 

Age  has  a  marked  bearing  on  fertility,  and  while  conception  is 
possible  at  any  time  from  the  beginning  of  menstruation  (puberty)  to 
its  close  (menopause),  there  are  certain  ages  which  are  more  fertile 
than  others.  From  the  investigations  of  Matthews  Duncan,  twenty 
to  twenty-four  years  of  age  may  be  taken  as  the  period  of  maximum 
fertility  for  the  female,  so  that  early  marriages  are  highly  desirable 
from  the  standpoint  of  fertility.  Duncan's  comments  on  the  results  of 
his  studies  were  most  interesting  and  he  concluded  "that  about  seven 
per  cent  of  all  the  marriages  between  fifteen  and  nineteen  years  of  age 
inclusive  are  without  offspring;  that  those  married  at  ages  from 
twenty  to  twenty-four  inclusive  are  almost  all  fertile;  and  that  after 
that  age,  sterility  gradually  increases  according  to  the  greater  age  at 
the  time  of  marriage."  His  study  of  this  question  still  remains  the 
standard,  and  its  accuracy  has  never  been  challenged. 

Acquired  Sterility. — Acquired  sterility  may  be  either  absolute 
(tubal  occlusion)  or  relative  (fibroids,  displacements,  endometritis). 
While  disease  or  injury  can  so  affect  or  close  the  genital  passages  as 
to  preclude  intercourse,   and  thereby  render  conception   impossible. 


ETIOLOGY  49 

inflammation  of  the  fallopian  tubes  is  probably  the  most  Important 
cause  of  acquired  sterility.  Such  inflammation  is  in  the  overwhelming 
majority  of  cases  produced  by  gonorrhea.  The  ravages  of  this  disease 
generally  so  seals  off  the  tubes  as  to  make  the  sterility  absolute,  and 
from  which  the  woman  never  recovers  except  through  surgical  meas- 
ures. But  a  very  small  percentage  of  occluded  tubes  is  the  result  of 
outside  involvement  from  the  spreading  inflammation  of  appendicitis 
or  pelvic  peritonitis. 

Gonorrhea  is  more  prevalent  than  syphilis  and  while  not  so  fatal 
to  the  individual  or  his  progeny  is  yet  the  cause  of  far  greater  ill  health 
to  the  community.  It  is  a  disease  in  which  it  is  often  difficult  to  effect 
a  permanent  cure,  and  in  many  cases  that  are  supposedly  cured,  the 
infected  organism  may  still  lurk  in  some  portion  of  the  generative  tract 
entirely  unsuspected,  only  to  break  out  afresh  in  after  years. 

While  gonorrhea  is  a  sufiflciently  serious  disease  in  the  male,  it  is 
vastly  more  so  in  the  female,  being  responsible  for  from  fifty  to  eighty 
per  cent  of  all  cases  of  chronic  inflammation  of  the  pelvic  organs.  Its 
ravages  render  the  great  majority  of  such  cases  chronic  invalids  for 
life.  Syphilis,  on  the  other  hand,  is  one  of  the  main  causes  of  death 
of  the  fetus,  both  in  early  and  late  pregnancy,  and  is  a  frequent  cause 
of  abortion,  premature  birth,  and  fetal  death  during  labor.  In  England 
and  Wales  it  has  been  estimated  that  27,000  deaths  occur  annually 
from  syphilis  during  the  ante-natal,  Intro-natal,  and  neo-natal  periods. 
In  the  urban  districts,  twenty-five  per  cent  of  the  total  ante-natal 
deaths  and  deaths  during  the  two  to  three  weeks  after  birth  were  due 
to  a  syphilitic  infection  of  the  fertilized  ovum  or  fetus ;  while  twenty 
per  cent  would  seem  to  be  a  fair  average  for  the  whole  of  England  and 
Wales.  In  the  United  States,  general  statistics  are  unavailable,  so  that 
we  are  obliged  to  fall  back  on  hospital  records.  In  10,000  consecutive 
labors  reported  from  the  Johns  Hopkins  Hospital  in  Baltimore,  thirty- 
two  per  cent  of  the  total  deaths  up  to  fourteen  days  after  birth,  were 
due  to  syphilis,  while  in  the  Sloane  Hospital  in  New  York,  nine  per 
cent  of  the  still  births  were  syphilitic.  It  has  been  calculated  that 
among  the  working  classes  at  least  eight  to  twelve  per  cent  of  the  adult 
males  have  acquired  syphilis  and  at  least  three  to  seven  per  cent  of  the 
adult  females  are  similarly  infected. 

The  fetus  in  utero  Is,  as  a  rule,  amply  protected  by  the  security  of 
Its  domicile,  not  only  from  accidents  but  also  from  maternal  Infection 
by  virtue  of  the  distribution  of  all  ferments  derived  from  the  cells  of 
the  feta  chorion.     These  ferments  or  their  derivatives  act  as  a  verv 


so  STERILITY  AND  CONCEPTION 

efficient  chemical  filter,  destroying  or  breaking  up  into  granules  germs 
such  as  the  tubercle  bacilli  and  the  spirochseta  pallida  of  syphilis.  It 
has  been  shown  by  Noguchi  that  these  granules,  in  the  case  of  spiro- 
chaetes,  while  they  may  remain  inactive  biologically  over  long  periods 
of  time,  can  later  develop  into  mature  spirochaetes  with  fully  retained 
powers  of  infectivity.  If  the  chorion  ferments  are  able  to  control  the 
activity  of  the  granules  during  pregnancy,  as  it  would  seem  quite  prob- 
able they  are,  then  with  their  disappearance  after  delivery,  it  would  be 
quite  possible  for  the  granules  to  develop  into  mature  organisms  so 
that  clinical  symptoms  of  syphilis  would  appear  in  both  parent  and 
offspring.  These  views  are  in  harmony  with  the  fact  so  often  demon- 
strated clinically,  that  active  anti-syphilitic  treatment  of  prospective 
mothers  during  their  period  of  gestation  prevents  many  an  abortion  or 
still-birth  and  often  results  in  the  birth  of  a  living  child  without 
blemish  or  taint.  When  such  treatment  has  been  intelligently  and 
faithfully  persisted  in,  even  though  it  was  not  begun  before  the  middle 
period  of  pregnancy,  I  have  frequently  seen  their  first  living  baby  born 
to  women  where  repeated  abortions  and  still-births  had  previously 
been  the  rule. 

Chronic  inflammation  with  a  thickening  of  the  lining  membrane  of 
the  uterus  (endometritis),  whether  the  result  of  post  infection,  or  con- 
sequent upon  a  displacement  of  the  uterus,  acts  as  a  frequent  cause  of 
sterility  by  interfering  with  the  proper  imbedding  and  growth  of  the 
fertilized  ovum;  while  a  chronic  inflammation  of  the  cervix  either 
from  infection,  displacement,  or  laceration,  will  often  cause  sterility  by 
producing  a  plugging  of  the  cervical  canal  with  an  excessive  and  patho- 
logical glandular  secretion  which  serves  as  a  very  efficient  barrier  to 
the  passage  of  the  spermatozoa. 

Fibroid  tumors  of  the  uterus  bear  a  most  important  relation  to 
fertility.  While  it  is  quite  true  that  many  women  grow  fibroids  and 
babies  indiscriminately,  and  in  large  numbers,  as  a  general  rule,  these 
growths  promote  sterility  and  retard  fertility.  Some  writers  have 
taken  the  stand  that  they  are  a  result  of  the  sterility  and  not  a  cause. 
Giles  has  reported  a  most  interesting  and  valuable  study  on  the  absence 
of  pregnancy  as  a  cause  of  fibroids  based  on  566  cases.  In  this  series 
all  the  patients  were  married  women  who  had  fibroids,  yet  sixty  per 
cent  had  never  been  pregnant.  In  support  of  his  contention  "that  they 
developed  fibroids  because  they  had  not  become  pregnant,"  he  gives 
two  reasons:  first,  that  they  had  been  married  long  enough  to  have 
been  pregnant,  seventy-five  per  cent  over  five  years,  and  forty-seven 


ETIOLOGY  SI 

per  cent  over  ten  years ;  arid  second,  that  the  great  majority  had  been 
married  a  long  time  before  the  fibroids  had  developed,  there  being  only 
a  few  cases  in  which  the  fibroid  history  went  back  more  than  three  to 
five  years.  But  it  is  difficult  to  say  when  any  fibroid  first  began  to 
grow,  and  quite  small  growths  may  early  occlude  the  cervical  canal, 
or  obstruct  the  tubal  opening,  preventing  the  passage  of  the  spermato- 
zoa, or,  when  in  the  uterine  cavity,  so  thicken  the  endometrium  as  to 
prevent  a  successful  imbedding  of  the  fertilized  ovum  long  before  the 
tumor  has  reached  a  sufficient  size  to  make  a  diagnosis  possible. 

Fibroids. — Fibroids  are  by  far  the  most  common  of  all  uterine 
neoplasms,  and  there  can  be  no  doubt  but  that  clinical  records  greatly 
understate  their  frequency.  This  is  due  probably  to  the  fact  that 
unless  they  enlarge  sufficiently  to  attract  attention  or  produce  well 
recognized  clinical  symptoms  they  are  often  overlooked. 

Closely  akin  to  fibroid  tumors  as  a  cause  of  sterility,  or  at  least  as 
a  factor  in  diminished  fertility,  is  the  condition  known  as  general 
uterine  fibrosis,  where  there  is  a  replacement  of  the  muscular  tissue  of 
the  uterus  by  fibrous  tissue.  This  causes  a  thickening  of  the  endo- 
metrium and  uterine  walls  which  is  associated  with  profuse  menstrua- 
tion and  at  times  actual  hemorrhage.  In  both  fibroids  and  general 
fibrosis,  the  accompanying  hyperplasis  of  the  endometrium  renders  it 
an  unfavorable  soil  for  the  lodging  and  maturing  of  the  fertilized 
ovum,  and  the  same  is  true  of  the  post-partum  sub-involuted  uterus. 
A  comparatively  small  fibroid,  when  situated  in  the  uterine  wall  or 
uterine  cavity,  is  more  likely  to  interfere  with  pregnancy  and  to  be 
a  cause  of  relative  sterility  than  a  large  pedunculated  one  lying  out- 
side of  the  uterus.  The  reason  for  this,  I  believe,  is  that  the  inter- 
uterine  and  intra-uterine  tumor,  being  an  irritant  foreign  body,  the 
uterus  is  continually  contracting  in  its  endeavor  to  expel  it,  and  this 
contraction  or  hyper-muscular  activity  keeps  the  uterus  in  an  almost 
tonic  state  of  contraction  which  eventually  throws  out  the  fertilized 
ovum  even  when  imbedding  has  occurred.  It  is  not  unusual  in  these 
cases  to  find  the  uterus  hypertrophied  to  several  times  its  normal  size. 
When  the  fibroid  is  removed  the  uterus  will  involute,  just  as  it  does 
after  labor,  returning  in  a  short  time  to  normal,  or  practically  normal 
size,  and  pregnancy  not  infrequently  follows  the  operation  with  grati- 
fying promptness.  The  subperitoneal  fibroids  seldom  ever  interfere 
with  pregnancy,  and  are  not  often  found  to  be  a  cause  of  sterility 
because  they  have  been  driven  out  of  the  uterus,  which  has  then  sub- 
sequently involuted  and  returned  to  a  state  of  quietude  such  as  invites 


52  STERILITY'  AND  CONCEPTION 

pregnancy.  This  theory  seems  to  me  to  cast  considerable  light  upon 
those  cases  where  fibroids  are  found  associated  with  long  periods  of 
sterility,  following  which  conception  spontaneously  occurs. 

Malignant  tumors  of  the  uterus  are  a  very  efficient  barrier  to  con- 
ception, for  which  we  should  be  duly  thankful. 

Retrodisplacements. — Retrodisplacements  of  the  uterus  play  an 
important  part  in  sterility  and  fertility,  but  to  just  what  extent  is  still 
a  matter  of  considerable  difference  of  opinion,  and  perhaps  justly  so. 
They  have  been  held  accountable  by  some  for  nearly  every  ill  and 
ailment  to  which  woman  is  prone,  and  by  others  swept  aside  as  utterly 
unimportant.  I  believe  they  should  be  considered  as  among  the  more 
frequent  causes  of  sterility.  In  this  respect  it  is  quite  necessary  to 
distinguish  between  congenital  or  acquired,  and  minor  and  major  dis- 
placements. In  the  congenital  type  of  case,  the  uterus  is  usually 
immature  and  the  sterility  probably  due  to  the  inability  of  the  unde- 
veloped organ  to  properly  function,  a  common  weakness  with  all  unde- 
veloped organs,  and  one  that  is  not  peculiar  to  the  uterus  alone.  The 
retroposed  uterus,  whether  of  the  congenital  or  acquired  type  is  by 
virtue  of  its  impaired  circulation,  in  a  state  of  chronic  venous  conges- 
tion, a  condition  unfavorable  to  conception,  and  even  when  conception 
occurs,  early  abortion  is  the  rule  unless  restitution  to  normal  position 
takes  place  spontaneously  or  is  induced.  These  cases  often  undergo 
repeated  abortions  without  ever  carrying  a  pregnancy  to  term  as  spon- 
taneous restitution  is  the  exception  rather  than  the  rule.  In  cases  of 
habitual  abortion  due  to  this  cause,  if  the  uterus  be  replaced,  the  next 
pregnancy  will  usually  go  on  without  interruption  to  term.  What  has 
been  said  regarding  the  minor  displacements  is  true  likewise  of  the 
major  displacements,  though  to  a  less  degree.  This  class  of  displace- 
ments does  not  often  enter  into  the  question  of  sterility,  but  prolapse 
of  the  uterus  is  the  one  which  has  to  be  occasionally  considered.  When 
the  prolapse  has  not  progressed  beyond  the  first  or  second  degree  it 
results  in  but  slight  impairment  of  the  procreative  function  of  the 
woman,  but  complete  or  third  degree  prolapse  is  attended  by  a  high 
rate  of  sterility  and  a  greatly  lessened  fertility. 

Regarding  the  influence  of  tumors  of  the  ovary  on  sterility  and 
fertility,  little  of  value  can  be  said  from  a  statistical  viewpoint,  and  the 
subject  has  to  be  considered  in  a  more  or  less  general  manner.  Ob- 
viously when  only  one  ovary  is  the  seat  of  disease,  the  other  being 
healthy,  there  need  be  no  interference  with  conception,  and  unilateral 


ETIOLOGY  S3 

tumors  should  not  be  classed  as  a  cause  of  sterility,  but  rather  as  a 
possible  cause  of  lessened  fertility.  The  question  of  a  bilateral  involve- 
ment is  of  much  greater  importance.  The  nature  of  the  new  growths 
has  much  to  do  with  the  prognosis.  Women  with  malignant  neoplasms 
and  dermoid  cysts,  growths  which  are  usually  bilateral,  are  as  a  rule 
sterile;  while  women  with  benign  ovarian  cysts  frequently  conceive, 
and  cases  of  pregnancy  with  double  ovarian  cysts  have  been  reported. 
A  high  rate  of  sterility  and  a  low  rate  of  fertility  is  the  rule  in  patients 
with  ovarian  cysts,  and  the  fact  that  these  growths  very  frequently 
complicate  pregnancy,  either  interrupting  or  necessitating  the  inter- 
ruption of  the  pregnancy,  justifies  their  consideration  as  a  cause  of 
sterility,  at  least  of  relative  sterility. 

Inflammatory  Processes. — Aside  from  new  growths  of  the 
ovary  as  a  cause  of  sterility,  the  inflammatory  involvements  deserve  a 
more  important  consideration  than  is  usually  accorded  them.  Quite 
often  the  ovaries  are  found  to  be  enclosed  in  a  veil  of  adhesions  which 
at  times  so  completely  envelop  them  as  to  prevent  the  ovum  after  lib- 
eration from  reaching  the  tubes,  yet  the  inflammatory  process  which 
caused  these  adhesions  may  not  have  involved  the  tubes  to  the  extent 
of  completely  closing  their  entrance.  Inflammatory  thickening  of  the 
cortex  and  capsule  of  the  ovary  will  in  itself  often  prevent  the  libera- 
tion of  the  ovum  and  thus  produce  sterility.  Such  inflammatory  con- 
ditions are  most  often  the  result  of  postabortive  or  postpartum  infec- 
tion and  are  only  rarely  caused  by  gonorrhea,  which  never  attacks  the 
ovary  primarily.  When  gonorrhea  attacks  the  ovary,  the  avenue  of 
approach  is  through  the  tube.  The  possibility  of  ovarian  inflammation 
as  a  complication  of  mumps  has  long  been  recognized,  ancf  in  this 
regard,  typhoid,  scarlet  fever,  and  diphtheria  should  be  more  thor- 
oughly studied.  I  have  occasionally  seen  when  operating  on  young 
girls,  even  before  puberty,  extensive  inflammatory  adhesions  sur- 
rounding the  ovaries  and  tubes,  and  matting  them  down  to  the  broad 
ligaments,  that  could  very  well  have  been  caused  by  mumps  or  one  of 
the  acute  exanthemata,  hardly  by  gonorrhea. 

The  functional  causes  of  sterility  are  complex  and  not  easy  of 
enumeration.  Good  health,  plenty  of  out-door  life  and  exercise,  are 
all  favorable  to  fecundity,  while  luxury  and  wealth  with  their  attendant 
evils  go  hand  in  hand  with  sterility. 

Alcoholism. — Parental  alcoholism  may  cause  serious  injury  to 
the  germ  cells,  as  has  been  shown  by  Stromayer,  Witterman  and 


54  STERILITY  AND  CONCEPTION 

Grossman,  and  their  conclusions  are  strongly  confirmed  by  the  experi- 
ments on  alcoholized  animals  carried  out  by  Stockard.  In  his  investi- 
gations he  found  that  normal  males  mated  with  alcoholized  females 
gave  forty  per  cent  still-born  or  offspring  that  died  within  three  months 
in  contrast  to  only  13.55  P^^  ^^^^  with  normal  mates.  In  the  series  of 
normal  matings  there  were  no  defective  young,  while  the  alcoholized 
series  showed  ten  per  cent  defectives. 

All  the  evidence  in  the  case  thus  far  collected  would  tend  to  estab- 
lish beyond  a  reasonable  doubt  the  fact  that  parental  alcoholism 
exercises  a  very  definite,  injurious  influence  on  the  birth  rate  from  a 
quantitative  as  well  as  a  qualitative  point  of  view,  and  that  alcohol  as 
a  racial  poison  plays  a  very  real  part  in  decreasing  fertility. 

There  can  be  little  doubt  that  postponement  of  the  age  of  marriage, 
whether  by  social  factors,  false  notions  of  the  standards  of  living,  or 
for  economical  reasons,  has  been  prejudicial  to  society  and  has  resulted 
in  a  serious  increase  in  immorality.  This  has  greatly  interfered  with 
and  decreased  the  normal  production  of  healthy  lives.  When  the 
individual  arrives  at  the  proper  physiological  age  for  marriage,  the 
sooner  legitimate  mating  takes  place  the  better  for  morality  and  for 
society.  The  postponement  of  marriage  after  this  age  is  reached  can- 
not but  result  in  social  unbalance,  and  in  many  ways  it  is  one  of  the 
greatest  sources  of  discord  in  our  modern  civilization. 

Great  stress  has  been  laid  upon  the  injurious  effect  of  repeated 
child  bearing  to  the  woman  and  this  has  been  brought  forward  prom- 
inently in  all  birth-control  propaganda.  Luther's  remark  regarding 
the  mother  who  died  early,  worn  out  by  excessive  child  bearing,  "What 
matter?  It  is  what  she  is  here  for,"  has  been  often  quoted  in  such 
"literature,"  but  frequent  child  bearing,  during  the  favorable  repro- 
ductive period  of  a  woman's  life,  does  not  necessarily  wear  her  out  nor 
bring  her  to  an  early  grave.  Indeed,  the  great  majority  of  women  are 
never  in  such  good  health  as  when  carrying  or  nursing  their  children. 
It  is  rather  on  the  shoulders  of  indifferent  and  careless  obstetrics 
that  the  blame  should  be  placed.  The  need  of  better  attention  during 
pregnancy  and  confinement  is  a  vital  one,  and  in  no  other  department 
of  medicine  or  surgery  is  the  care  of  the  patient  fraught  with  greater 
responsibility.  It  is  difficult  to  contemplate  without  a  shudder  the  vast 
horde  of  women  being  continually  condemned  to  lives  of  chronic 
invalidism  by  ignorant  midwifery;  the  countless  operations  yearly 
performed  to  correct  the  damage  done  by  unskillful  obstetrics;  the 


ETIOLOGY  55 

annual  erection  of  tombstones  to  those  who  become  martyrs  to  the 
cause,  without  fervently  praying  for  the  early  arrival  of  the  day  when 
the  practice  of  this  all-important  branch  of  medicine  will  be  limited  by 
law  to  those  specially  qualified  to  practice  it,  and  with  a  paternal  gov- 
ernment, humane  enough  and  farsighted  enough  to  zealously  guard 
the  interests  of  all  its  prospective  mothers. 

Alcohol,  vice,  and  immorality  are  responsible  for  a  large  percent- 
age of  sterility.  It  is  a  false  and  vicious  standard  of  morals  which 
opens  every  door  to  the  prodigal  son,  but  which  closes  every  door  to 
the  prodigal  daughter.  I  believe  that  if  any  difference  exists,  it  should 
be  in  favor  of  the  woman,  who  in  many  instances  has  not  only  to  resist 
her  own  physical  instincts  but  also  the  continual  attack  of  man. 

Physical  and  Mental  Incompatibility. — Sexual  gratification  of 
the  female  on  intercourse  is  not  necessary  to  conception;  nor  does  its 
absence  preclude  conceptibn,  but  incompatibility  of  sentiment  is  often 
a  factor  in  causing  sterility.  There  are  certain  varying  degrees  of 
affinity  which  are  unfavorable  to  fertility.  Consanguineous  marriages 
have  an  evil  influence.  A  single  child,  the  feeble  fruit  of  worn-out 
stock,  is  usually  low  in  fertility.  Three  years  of  married  life  should 
pretty  well  decide  the  question  of  probable  sterility,  for  it  has  been 
estimated  that  only  about  seven  per  cent  of  the  fertile  bear  their  first 
child  after  that  time. 

We  must  not  lose  sight  of  the  fact  that  in  cases  of  sterility,  the 
sexual  organs  or  functions  in  both  the  male  and  female  may  be  in  a 
perfectly  normal  condition  and  that  the  sterility  may  be  due  to  physical 
incompatibility  of  sentiment;  in  other  words,  that  sterility  may  be 
more  relative  than  absolute.  This  is  borne  out  by  many  instances 
where  the  husband  and  wife,  having  lived  together  for  many  years 
without  issue,  separate  and  remarry  and  each  has  a  family  by  the  new 
partner.  Also,  numerous  cases  have  been  reported  where  the  wife  was 
sterile  to  her  first  husband  who  had  had  children  by  a  former  wife,  and 
yet  after  the  death  of  this  husband  promptly  conceived  when  married 
a  second  time. 

LITERATURE 

Bandler.    a.  J.  S.    Sept.,  1912. 

DuLBERG,  Jos.     Sterile  Marriages.     19 19. 

Duncan,  J.  M.    Fecundity,  Fertility,  and  Sterility.     1871. 

Englemann,  G.  F.    J.  A.  M.  A.     Oct.,  1901. 


$6  STERILITY  AND  CONCEPTION 

Giles,  A.  E,    Sterility  in  Women.     1919. 

McCallum,  E.  V.     The  Newer  Knowledge  of  Nutrition.     1918. 
Marshall,  F.  H.     Physiology  of  Reproduction.     19 10. 
Osborne  and  Mendel.    Jour.  Biol.  Chem.     191 5  and  1918. 
Reynolds  and  Macomber.     Am.  Jour.  Obstet.  and  Gyn.     192 1. 
Stokard.      Proc.  Soc.  Exper.  Biology  and  Medicine,  1914. 
Stromayer.     Miinch.  med.  Wochenschrift.     1901. 


CHAPTER  VIII 

ETIOLOGY— DIAGNOSIS— TREATMENT 

Unfruitful  marriages— Quality  of  spermatozoa — Vitality,  number,  and  motility  of 
the  spermatozoa — Diagnostic  importance  of  vaginal  and  cervical  smears — 
Uterine  displacements — Male  sterility — Study  and  examination  of  the  male- 
Imperfect  sexual  relations — Study  and  examination  (pi  the  female — Rectal  ex- 
amination in  stout  subjects— Post  coital  tests  for  sterility — Determining  the 
potency  of  the  fallopian  tubes — No  infallible  test  of  sterility — Treatment  of 
sterility — Hygienic  measures. 

Unfruitful  Marriages. — Many  different  factors  may  contribute 
in  part  or  in  whole  to  the  tragedy  of  an  unfruitful  marriage.  In  the 
male,  the  absence  or  poor  quality  of  the  spermatozoa,  defective 
anatomy,  and  pathological  conditions  which  destroy  the  spermatozoa 
either  before  or  during  ejaculation  have  been  mentioned.  In  the 
female,  the  spermatozoa  may  be  destroyed  in  the  vagina  or  after  reach- 
ing the  cervix  or  even  the  uterus,  or  ovulation  may  be  defective  or 
absent  entirely.  Of  fascinating  interest  is  the  histological  study  of 
the  spermatozoa,  the  process  of  ovulation  and  fecundation,  and  the 
vaginal  and  uterine  secretions  in  their  bearing  on  sterility.  Along  this 
line  the  work  of  Reynolds,  Lespinossi,  Huhner,  Detlefsen,  and 
Rohleder  deserves  the  greatest  praise,  and  these  should  be  read  in  full 
in  order  to  gain  a  clear  understanding  of  the  details  and  technical 
methods  used. 

Quality  of  Spermatozoa. — A  few  motile  spermatozoa  found  in 
the  semen  do  not  by  any  means  give  a  reasonable  hope  of  fertility. 
Lade  has  estimated  200,000,000  as  the  number  of  spermatozoa  present 
in  a  single  ejaculation,  only  one  of  which  eventually  produces  the 
impregnation.  With  such  a  great  numerical  waste,  quality,  rather 
than  quantity  becomes  the  important  consideration,  yet  Detlefsen,  upon 
dividing  433  specimens  of  semen  into  four  classes  according  to  the 
numerical  distribution  of  spermatozoa,  and  then  again  into  four  classes 
with  reference  to  motility,  found  by  subsequent  breeding  experiments 
that  without  exception  an  animal  might  be  regarded  as  sterile  unless 
both  numerical  frequency  and  motility  were  at  least  of  the  second 

S7 


58  STERILITY  AND  CONCEPTION 

class;  i.e.,  unless  the  animal  was  in  one  of  the  first  four  of  the  sixteen 
classes  so  produced. 

Vitality,  Number  and  Motility  of  the  Spermatozoa. — Reynolds's 
studies  have  gone  even  farther  and  tend  to  show  that  in  estimating  the 
fertility  of  the  male  the  vitality  of  the  spermatozoa  must  be  studied  as 
well  as  their  numerical  frequency  and  motility.  His  work  in  this 
respect  is  of  great  clinical  value  and  has  led  to  the  development  of  a 
comparatively  rapid  method  for  the  estimation  of  vitality. 

Vaginal  and  Cervical  Smears. — After  a  careful  inquiry  mto  the 
patient's  past  and  present  marital  relations  a  thorough  microscopical 
examination  of  smears  taken  from  the  vagina  and  cervical  canal  within 
two  hours  after  normal  intercourse  should  be  made.  These  will  readily 
demonstrate  the  presence  or  absence  of  spermatozoa.  It  is  not  unusual 
at  this  time  to  find  only  dead  spermatozoa  in  the  vagina,  but  from  the 
cervical  canal  it  should  be  possible  to  obtain  live  and  active  examples. 
In  making  a  large  number  of  such  examinations  one  cannot  but  be 
impressed  by  two  important  facts :  ( i )  that  far  less  often  are 
spermatozoa  found  in  the  genital  tract  of  sterile  women  than  in  fruit- 
ful ones.  (2)  Rarely  if  ever  are  spermatozoa  found  in  the  cervical 
canal  beyond  the  occluding  mucus  plug  of  a  chronic  cervicitis.  Though 
I  have  repeatedly  found  them  enmeshed  in  the  mucus  plug  in  multipara 
as  well  as  in  nullipara,  and  in  the  former  occasionally  beyond  the 
barrier  of  the  plug,  I  have  rarely  found  them  to  have  penetrated  the 
plug  and  reached  the  cervical  canal  beyond  in  nullipara.  In  nullipara 
the  cervical  canal  is  small,  and  where  chronic  cervicitis  exists,  always 
more  tightly  plugged  than  in  multipara.  Frequently  in  these  cases,  it  is 
possible  by  suction  with  the  Bier's  cup  to  draw  out  a  complete  mucus 
cast  of  the  cervical  canal. 

When  these  microscopical  details  have  been  elicited,  the  physical 
examination  should  next  be  taken  up.  By  the  bimanual  abdominal  and 
vaginal  examination  the  size,  position,  and  mobility  of  the  uterus  are 
determined,  and  any  abnormality  in  the  region  of  the  adnexa  noted. 
The  infantile  type  of  uterus  is  unfavorable  to  fecundity,  as  is  the 
small,  anteflexed  organ.  Conception,  to  be  sure,  occasionally  occurs  in 
the  undeveloped  uterus,  but  this  is  the  exception  rather  than  the  rule, 
and  the  first  pregnancy  seldom  goes  on  to  term,  early  abortion  gen- 
erally resulting.  The  added  development  which  the  uterus  acquires  as 
a  result  of  this  miniature  labor  is  then  usually  sufficient  to  enable  it  to 
carry  the  next  and  succeeding  pregnancies  to  a  successful  issue.    In  the 


ETIOLOGY—DIAGNOSIS— TREATMENT  .     S9 

infantile  uterus,  where  pregnancy  has  never  taken  place,  much  may  be 
accomplished  in  selected  cases  by  dilating  the  cervix  and  packing  the 
uterine  cavity  tightly  with  gauze.  This  method  of  treatment,  in  imita- 
tion of  nature,  stimulates  the  uterus  and  frequently  results  in  a  further 
development  that  cures  the  sterility. 

Uterine  Displacements. — The  anteflexed  uterus  is  a  maldevel- 
oped  type,  and,  although  it  does  not  carry  with  it  a  normal  rate  of  fer- 
tility, is,  by  no  means  a  barrier  to  conception.  Many  such  uteri  undergo 
even  repeated  pregnancies  and  in  quite  a  large  percentage  the  ante- 
flexion persists.  In  all  probability  the  high  rate  of  sterility  and  the 
low  rate  of  fertility  in  anteflexion  is  due  to  the  undeveloped  condition 
of  the  organ  rather  than  to  the  angle  of  flexion,  and  I  cannot  but  feel 
that  the  various  operations  so  frequently  advised  for  the  correction  of 
this  angle  of  flexion,  with  the  idea  that  it  is  an  etiological  factor  in 
the  sterility,  are  ill  advised. 

Displacements  of  the  uterus,  especially  retroflexion,  should  be  cor- 
rected, because  the  congestion  in  the  organ  with  the  thickening  of  the 
endometrium  resultant  on  the  displacement  lessens  very  materially  the 
chance  of  a  permanent  imbedding  of  the  fertilized  ovum.  The  replace- 
ment can  often  be  accomplished  by  nonoperative  means,  and  these 
should,  as  a  rule,  always  be  given  a  trial  first.  The  pessary  to  hold  the 
uterus  in  place  is  of  great  value  in  the  treatment  of  relative  sterility 
due  to  this  cause.  Laceration  of  the  cervix  through  the  internal  os, 
and  lacerations  accompanied  by  marked  erosion  or  chronic  inflamma- 
tion of  the  cervical  glands,  should  be  repaired.  Subinvolution  of  the 
uterus  may  be  an  indication  for  curettage  if  it  does  not  yield  to  simpler 
methods  of  treatment.  The  tumors  of  the  uterus  usually  call  for  their 
removal.  Enlargement  of  the  adnexa  is  an  indication  for  their  oper- 
ative inspection  when  the  tubes  will  often  be  found  closed.  After 
opening  the  occluded  end,  the  tube  should  be  probed  its  entire  length 
into  the  uterine  cavity  to  make  sure  of  its  patency,  and  occasionally  an 
obliterative  salpingitis  involving  the  whole  tube  will  be  encountered, 
although  it  is  more  common  to  meet  with  only  partial  obliteration. 
Rarely,  if  ever,  is  a  tube  found  occluded  at  its  cornual  end  when  the 
rest  of  its  lumen  is  free. 

Sterility  in  the  Male. — The  importance  of  the  part  played  by 
the  male  in  sterile  marriages  has,  up  to  a  comparatively  short  time 
ago,  not  been  sufficiently  recognized.  It  has  been  a  question 
seemingly  so  confused,  or  rated  of  so  little  consequence,  that  few 
writers  have  tried  to  understand  its  real  significance. 


6o    .  STERILITY  AND  CONCEPTION 

This  state  of  affairs  has  been  extremely  unfortunate,  because  it  has 
hindered  a  clearer  understanding  of  the  subject  of  sterility,  thrown 
much  unfair  blame  on  the  female,  and  prevented  the  acquiring  of 
information  most  valuable  in  diagnosis,  prognosis  and  treatment. 
Furthermore,  the  neglect  of  this  subject  has  rendered  the  statistics,  and 
a  great  part  of  the  writings  of  the  earlier  investigators  of  little  or  no 
present  use.  Even  to-day  few  physicians  have  made  themselves 
familiar  with  this  subject,  and,  as  a  result,  there  are  many  profes- 
sional minds  in  which  it  is  still  shrouded  with  the  mystery  which  begets 
ignorance. 

The  fertilizing  element,  the  semen,  is  the  product  of  the  male 
genital  organs,  and  consists  of  a  mixture  of  various  gland  products 
derived  from  the  sexual  apparatus;  the  testicles,  the  seminal  vesicles, 
the  vas  deferens,  the  epididymis,  Cowper's  glands  and  the  prostate 
gland  all  being  contributors.  The  details  of  the  preparation  of  this 
fluid  is  far  from  having  been  satisfactorily  explained,  but  the  greatest 
interest  centers  around  the  seminal  corpuscles,  or,  as  they  are  more 
often  called,  the  spermatozoa.  These  come  from  the  testicles,  and 
each  has  a  very  definite  entity,  consisting  of  a  head,  a  middle  piece  and 
a  tail  (Fig.  ii,  p.  35).  The  head,  or  as  it, may  properly  be  called,  the 
nucleus,  is  the  important  fertilizing  element,  and  measures  about 
0.0006  millimeter.  The  tail  is  the  organ  of  propulsion,  and  at  the  full 
height  of  its  vitality  is  able  to  drive  the  spermatozoa  forward  at  the 
rate  of  from  2  to  3  millimeters  a  minute. 

The  spermatozoa  do  not  normally  leave  the  testicles  until  the  time 
of  ejaculation,  and  the  presence  of  these  sperm  corpuscles  in  his  semen 
determines  the  fertilizing  power  of  the  man. 

Under  favorable  conditions  the  spermatozoa  are  very  tenacious  of 
life,  withstanding  considerable  variation  in  temperature,  and  have  been 
found  to  retain  their  vitality  in  frozen  semen  for  six  days,  and  in  an 
incubator  at  a  normal  blood  temperature  for  eight  days.  Extremes  of 
temperature,  above  47°  and  below  15°  centigrade,  destroy  them.  They 
have  been  found  alive  in  the  female  genital  tract  for  a  period  of 
twenty-five  days.  Alkaline  fluids  favor  their  life,  while  acid  media 
hasten  their  death. 

Virility  in  the  male  usually  begins  with  the  eighteenth  year,  and 
from  then  on  increases  up  to  about  the  fortieth  year,  after  this  there 
is  a  gradual  but  progressive  decrease  in  power,  although  its  ending  is 
not  marked  by  a  definite  climacteric,  as  is  the  case  in  the  female.    By 


ETIOLOGY— DIAGNOSIS— TREATMENT  6i 

the  sixty-fifth  year  comes  usually  a  complete  extinction,  though  some 
retain  their  sexual  power  well  into  the  seventies,  and  a  few  to  even 
more  advanced  years. 

The  first  duty  of  the  physician  when  consulted  in  a  case  of  sterility 
is  to  decide  whether  or  not  the  man  is  fertile,  and,  judging  from  my 
own  experience  with  these  cases,  a  much  larger  percentage  of  the  men 
than  is  generally  conceded  are  found  to  be  sterile.. 

I  firmly  believe  that  in  every  sterile  marriage,  no  matter  how  gross 
the  lesion  found  in  the  wife,  the  possible  responsibility  of  the  husband 
should  never  be  overlooked,  and  that  his  condition,  therefore,  should 
be  thoroughly  investigated  before  placing  the  blame  on  her. 

The  question  of  fertility  or  sterility  is,  in  the  man,  one  much  easier 
of  decision  than  in  the  woman,  and  is,  in  the  majority  of  cases,  one 
well  within  the  ability  of  the  general  practitioner  to  decide. 

In  order  to  successfully  impregnate  his  partner  it  is  necessary  for 
the  man  to  do  more  than  merely  accomplish  the  sexual  act.  With 
many,  however,  a  successful  cohabitation  is  taken  to  be  a  sufficient 
guarantee  of  his  fertility,  and  often  no  further  proof  is  required.  This 
view  of  the  matter,  commonly  accepted  by  the  laity,  is  only  too  fre- 
quently shared  likewise  by  physicians.  The  male  must  be  able  not  only 
to  properly  perform  the  sexual  act  but  to  deposit  live  and  healthy 
spermatozoa  in  plenty  in  the  cervical  canal,  or  at  least  in  the  immediate 
vicinity  of  the  cervix.  This  takes  place  at  the  time  of  ejaculation,  and 
while,  in  certain  cases,  impregnation  has  resulted  from  the  simple 
deposition  of  the  spermatozoa  in  the  vagina,  or  even  on  the  external 
genitalia,  without  any  penetration,  such  instances  are  rare,  and  are  the 
exception  to  the  rule. 

If,  then,  his  spermatozoa,  normal  and  healthy,  are  found  on  exam- 
ination at  the  external  cervical  os,  the  husband  can  be  freed  from  all 
responsibility  for  the  sterility.  The  specimen  (Condom)  test  so  often 
depended  upon  is  unreliable  unless  spermatozoa  are  never  present,  and, 
even  when  found  alive  and  in  plenty  on  repeated  examinations,  he  may 
still  be  sterile  from  the  presence  of  some  congenital  or  acquired  defect 
that  during  normal  intercourse  prevents  the  proper  ejaculation  of  the 
spermatozoa  against  the  cervix. 

Inability  to  properly  perform  the  sexual  act  Is  known  as  "Im- 
potentia  coeundi,"  while  inability  to  procreate,  or  sterility,  is  called 
"impotentia  generandi."  As  any  deformity  which  makes  proper 
cohabitation  impossible  will  likewise  prevent  conception,  absence  of  the 


62  STERILITY  AND  CONCEPTION 

penis  or  its  diminutive  size,  or  well  marked  hypospadias  or  epispadias, 
may  all  be  causes  of  sterility,  and,  with  organic  lesions  of  the  central 
nervous  system  controlling  the  sexual  function,  are  known  as  organic 
impotence. 

While  the  above-mentioned  conditions  may  be,  and  often  are,  the 
cause  of  nonimpregnation,  they  may  at  times  be  a  deterrent  factor 
only,  and  be  overcome  and  impregnation  successfully  brought  about  if 
the  semen  is  normal.  Thus,  true  sterility  in  the  male  may  be  said  to 
exist  only  in  the  absence  of  semen  (aspermia)  or  when  there  are  no 
spermatozoa  present  in  the  semen  (azoospermia).  When  the  semen  is 
present,  yet  shows  a  marked  decrease  in  quantity,  or  in  the  amount  of 
its  fertilizing  constituents,  the  condition  is  spoken  of  as  "oligo- 
spermia." 

Aspermia  may  be  caused  by  the  inability  of  the  semen  to  pass 
through  the  genital  canal,  the  obstruction  to  its  passage  being  either 
congenital  or  acquired.  In  the  former  the  sterility  is  usually  absolute, 
while  in  the  latter  it  may  be  only  relative,  the  result  of  injury,  general 
physical  deterioration,  or  the  same  causes  that  produce  the  various 
nervous  forms  of  impotence. 

Again,  partial  or  complete  absence  of  spermatozoa  may  be  either 
temporary  or  permanent. 

As  the  spermatozoa  come  from  the  testicles,  testicular  absence  or 
disease  may  be  a  cause  of  sterility,  and,  likewise,  the  absence  of  the 
epididymis  or  the  inflammatory  occlusion  of  the  spermatic  duct  may 
be  the  factor  responsible. 

A  physiological  diminution  or  complete  absence  of  the  spermatozoa 
is  seen  in  various  constitutional  diseases,  such  as  alcoholism,  chronic 
seminal  vesiculitis,  prostatitis,  posterior  urethritis  and  from  a  too  fre- 
cjuent  sexual  indulgence,  as  is  the  case  in  the  sexual  bankrupt.  When 
the  aspermatism  is  absolute  a  proper  ejaculation  may  never  have  been 
accomplished,  as  is  the  case  when  it  is  of  congenital  origin,  or  there 
may  be  only  a  partial  or  temporary  failure,  as  seen  in  the  acquired 
types,  yet  these  may  be  as  complete  and  permanent  as  though  con- 
genital. 

The  most  frequent  local  causes  found  to  be  responsible  are  mal- 
formations and  twists  in  the  posterior  urethra,  the  result  of  traumat- 
ism, whether  from  injury  or  operation,  and  as  a  result  of  which  the 
semen  is  thrown  back  into  the  bladder,  and  not  forward  through  the 
anterior  urethra. 


ETIOLOGY— DIAGNOSIS— TREATMENT  63 

Absence  of  the  testicles  (anorchism)  is,  of  course,  a  cause  of 
absolute  sterility,  while  the  condition  of  undescended  testicle  (cryptor- 
chidism) when  present  usually  causes  sterility.  Bilateral  closure  of 
the  spermatic  duct  at  any  point  in  its  course  from  the  epididymis  to 
the  ampulla  of  the  vas  deferens  is  most  often  the  result  of  inflamma- 
tion, and  causes  absolute  sterility.  Gonorrhea  is  the  greatest  factor 
in  causing  such  inflammation,  and  is  generally  considered  in  male 
sterility  to  be  a  more  important  factor  than  are  all  other  causes  com- 
bined. 

Psychical  Impotence. — Numerous  cases  are  encountered  where  the 
impotence  is  purely  psychical,  and  these  should  be  placed  in  a  class  by 
themselves,  although  it  is  the  custom  with  many  to  include  cases  of 
sexual  perversion  associated  with  impotence  in  the  same  class.  In 
the  perversion  cases,  while  impotence  is  frequently  associated  with  the 
perversion,  it  exists  only  as  an  associated  factor,  and  is  not  a  chief 
characteristic. 

In  psychical  impotence  virility  is  absent,  being  inhibited  by 
psychical  processes,  but  sexual  desire  is  normal.  This  psychical  in- 
hibitory power  results  usually  in  an  absence  of  erection  and  ejacula- 
tion, though,  in  some,  ejaculation  may  take  place  even  without 
erection. 

There  are  various  kinds  of  psychical  processes  that  lead  to  im- 
potence but  they  are  all  generally  based  upon  the  emotions,  and  the 
most  usual  one  is  the  fear  in  the  mind  of  the  man  that  on  trial  he  may 
prove  to  be  impotent.  The  majority  of  these  patients  are  of  the 
neurasthenic  type,  whom  sexual  excesses,  usually  in  the  form  of  mas- 
turbation, has  robbed  of  a  certain  degree  of  their  manhood,  leaving 
them  fearful  of  a  successful  result  when  they  come  to  face  the  final 
test.  Another  qujte  common  inhibiting  emotion  in  my  experience  is 
the  fear  on  the  husband's  part  of  impregnating  his  wife,  and  thus  sub- 
jecting her  later  to  the  sufferings  of  labor,  which,  in  his  mind,  are 
greatly  exaggerated.  In  one  of  my  cases  of  sterility  this  was  the 
state  of  mind  of  the  husband  who,  shortly  before  marriage,  had  been 
forced  to  listen  the  night-long  to  the  labor  cries  of  an  unanesthetized 
woman  in  a  neighboring  room.  Occasionally  a  husband  is  met  with 
who  considers  any  sexual  feeling  as  a  profanation  of  their  love,  and 
a  direct  insult  to  his  wife. 

There  are  many  other  emotions  which  at  times  produce  a  marked 
fear  of,  or  a  distaste  for,  intercourse,  and  that  are  capable  of  prevent- 
ing erection,  and  thereby  causing  impotence. 


64  STERILITY  AND  CONCEPTION 

The  X-ray  exerts  a  marked  sterilizing  influence  on  both  male 
and  female.  Prolonged  and  frequent  exposure  in  the  male  destroys 
the  spermatozoa,  but  does  not  affect  the  power  to  cohabit. 

From  a  perusal  of  this  necessarily  brief  enumeration  of  the  more 
important  conditions  which  influence,  to  a  greater  or  less  degree, 
sexual  virility,  it  will  be  readily  seen  that  there  are  at  times  so  many 
and  such  varied  causes  leading  to  sterility  that  questions  of  diagnosis 
and  treatment  require  a  special  treatise  by  themselves.  For  this  the 
reader  must  turn  to  the  literature  of  urology. 

The  whole  question  of  male  sterility  is  of  great  individual  and 
social  importance,  for,  as  Vecki  says,  "without  virility  there  can  be  no 
procreation."  Impotence,  when  premature,  often  transforms  the 
whole  character  of  the  man,  producing  changes  that  alienate  his  wife, 
his  children  and  his  friends,  often  bringing  failure  when  success 
seemed  assured,  and  leading  inevitably  to  the  wreck  of  his  home  and 
the  blasting  of  his  career. 

Study  and  Examination  of  the  Male. — In  taking  up  the  study 
of  an  individual  case  of  marital  unfruitfulness,  various  impor- 
tant points  must  be  kept  constantly  in  mind.  While  it  is  true  that 
too  much  stress  is  at  times  laid  upon  the  part  played  by  the  female,  and 
many  a  woman  unjustly  blamed  as  the  cause  of  the  sterile  marriage,  it 
is  likewise  true  that  the  fertility  of  the  male  is  far  too  often  taken  for 
granted.  Male  sterility  is  just  as  important  as  female  sterility,  and  in 
all  probability  fully  as  frequent.  In  many  childless  marriages  the 
cause  can  only  be  determined  by  microscopic  examinations,  so  that  to 
make  a  diagnosis  of  the  cause  of  the  sterility  calls  for  a  detailed 
microscopical  as  well  as  a  physical  examination.  The  examination  of 
the  man  is  best  carried  out  by  the  urologist,  whose  complete  report 
should  be  in  the  hands  of  the  gynecologist  when  he  starts  his  examina- 
tion of  the  woman.  The  examination  is  now  begun  by  taking  a  careful 
and  thorough  history,  going  into  even  the  most  minute  details,  and 
should  then  be  followed  by  a  general  physical  as  well  as  a  careful  local 
examination.  The  history  should  cover  fully  the  ground  of  the 
venereal  diseases  and  any  general  infection  from  which  the  patient 
may  have  suffered,  with  special  reference  to  any  past  attack  of  peri- 
tonitis, so  called,  or  appendicitis.  A  statement  by  the  patient  suggestive 
of  any  pelvic  or  abdominal  involvement,  past  or  present,  should  be 
most  thoroughly  investigated.  If  contraceptives  have  been  used  over 
any  considerable  period  of  time,  the  measures  employed  should  be 


ETIOLOGY— DIAGNOSIS— TREATMENT  .65 

inquired  into.  The  fertility  of  the  parents  and,  when  accessible,  that 
of  the  grandparents  should  be  noted.  The  next  question  to  be  taken 
up  is  that  of  the  menstruation,  and  any  abnormality  in  this  respect 
calls  for  careful  investigation.  This  may  show  a  late  onset,  with 
scanty,  irregular,  and  painful  periods,  suggestive  of  undeveloped  pelvic 
organs,  or  a  profuse  and  too  frequent  flow,  pointing  towards  a  retro- 
displacement,  subinvolution,  or  the  presence  of  a  uterine  fibroid.  When 
several  months  are  missed  at  a  time,  and  the  patient  has  "flashes"  of 
heat  and  cold,  the  menopause  may  be  judged  to  be  impending.  Follow- 
ing the  taking  of  the  menstrual  history,  the  patient  should  be  asked  if 
there  is  any  leucorrheal  discharge,  and  if  so,  its  character.  A  thin,  white 
discharge  is  indicative  of  chronic  endometritis,  while  a  thick,  stringy, 
white  or  yellowish  discharge  usually  accompanies  a  chronic  inflamma- 
tion of  the  cervix.  When  the  discharge  is  profuse  and  purulent  with 
marked  symptoms  of  vaginal  inflammation  and  frequent  urinations, 
gonorrhea  should  always  be  suspected. 

Pain  is  an  unreliable  symptom  on  which  too  much  importance  is 
often  placed.  When  accompanying  menstruation,  it  is  most  often 
indicative  of  undeveloped  organs  or  the  presence  of  fibroids,  .while 
when  present  between  menstruations  would  point  more  to  inflamma- 
tion, new  growths,  or  adhesions  of  the  adnexia.  Sacral  backache, 
while  generally  associated  with  retrodisplacements,  is  very  frequently 
present  without  any  discoverable  cause,  and  is  one  of  the  least  under- 
stood of  gynecological  symptoms. 

Imperfect  Sexual  Relations. — Now  comes  a  careful  inquiry 
into  the  patient's  sexual  relations,  which  will  surprisingly  often 
elicit  the  fact  that  a  normal  intercourse  has  never  taken  place.  This 
may  have  been  only  the  result  of  ignorance  as  to  how  to  properly 
perform  the  act,  or  a  successful  consummation  may  have  been  pre- 
vented by  some  pathological  obstruction,  such  as  a  rigid  hymen  or 
atresia  of  the  vagina.  Again,  intercourse  may  never  have  been  suc- 
cessful because  at  each  attempt  the  patient  was  thrown  into  such  a 
spasm  of  nervous  fear  as  to  render  it  impossible  (vaginismus),  or 
because  all  attempts  at  coitus  proved  so  painful  that  it  was  not  per-* 
sisted  in  (dyspareunia).  Both  vaginismus  and  dyspareunia  are  quite 
frequent  causes  of  sterility,  the  former  is  functional  and  at  times  very 
difficult  to  cure,  but  the  latter  is  generally  dependent  upon  some  inflam- 
matory disease  of  the  vulva,  vagina,  or  pelvic  organs,  and  usually 
yields  to  appropriate  treatment. 


66  STERILITY  AND  CONCEPTION 

Study  and  Examination  of  the  Female. — A  carefully  taken 
and  thoroughly  studied  history  will  often  point  the  way  to  a  cor- 
rect diagnosis  of  the  cause  of  the  sterility.  Many  times  even  before 
this  is  completed,  one  has  often  gained  a  pretty  clear  idea  as  to  just 
where  to  look  for  the  seat  of  trouble,  but  this  fact  should  not  be 
allowed  to  lead  to  neglect  in  the  slightest  degree  any  detail  of  the 
subsequent  examination.  It  is  important  to  bear  in  mind  in  this  con- 
nection that  there  are  many  more  or  less  pathological  conditions 
encountered  in  women  which,  while  they  may  and  often  do  produce 
active  symptoms  of  one  kind  or  another,  have  yet  in  themselves  no 
bearing  on  either  her  sterility  or  fertility. 

The  local  examination  of  the  patient  which  follows  should  be 
deliberate  and  thorough,  yet  always  conducted  with  due  regard  for  her 
feelings,  both  mental  and  physical.  Extreme  gentleness  is  necessary 
at  all  times,  especially  in  palpating  the  pelvic  organs.  To  cause  pain 
by  the  examination  greatly  increases  its  difficulty,  often  defeats  its 
object,  and  frequently  drives  the  patient  elsewhere.  If  your  first 
examination  is  not  entirely  satisfactory,  do  not  give  an  opinion  until 
you  have  made  a  subsequent  one  that  is. 

While  the  examination  is  being  conducted,  the  patient  should  lie 
on  the  table  comfortably  relaxed,  with  her  legs  supported  in  stirrups 
and  suitably  draped.  The  external  genitalia  are  first  inspected  and 
carefully  examined  for  any  abnormality  in  development  or  sign  of 
inflammation,  past  or  present,  of  the  vulvo-vaginal  glands,  their  ducts, 
or  the  peri-urethral  gland  ducts.  Inflammation  of  these  structures  is 
highly  significant  of  a  past  attack  of  gonorrhea.  A  vaginal  speculum  is 
now  introduced  and  by  shifting  its  position,  the  walls  of  the  vagina  are 
carefully  examined.  Smears  of  any  discharge  should  be  made  for 
microscopical  study  and  the  chemical  reaction  of  the  vaginal  secretion 
tested ;  for  a  highly  acid  secretion  has  a  lethal  effect  upon  the  spermato- 
zoa and,  therefore,  an  important  bearing  upon  the  question  of  sterility. 
The  cervix  is  now  examined  for  any  extensive  erosion,  either  con- 
genital or  acquired.  Such  are  often  associated  with  a  chronic  cer- 
vicitis and  accompanied  by  a  profuse  discharge  that  so  constantly  plugs 
the  cervical  canal  as  to  often  effectually  exclude  the  spermatozoa. 
Acquired  erosion  of  the  cervix  is  the  result  of  laceration,  and  any 
extensive  laceration  should  be  investigated;  for  these,  when  they 
involve  the  internal  os,  are  a  very  frequent  cause  of  habitual  abortion. 

The  size  of  the  external  os  is  of  importance,  for,  although  the 
so-called  pin-hole  os  may  not  in  itself  be  a  cause  of  sterility,  such  a 


ETIOLOGY— DIAGNOSIS— TREATMENT  6^ 

minute  opening  is  more  easily  plugged  by  mucus  and  the  spermatozoa 
thereby  excluded.  Mucus  blocking  of  the  cervical  canal  should  there- 
fore always  be  investigated,  and  it  is  important  to  distinguish  between 
the  thin,  glairy,  translucent  mucus,  which  is  normal,  and  the  thick, 
tenacious,  opaque  mucus,  which  is  pathological.  Smears  from  the 
cervical  canal  should  be  examined  for  infective  organisms,  and  the 
reaction  of  its  secretion  tested.  An  abnormally  high  alkalinity  is 
detrimental  to  the  life  and  activity  of  the  spermatozoa,  just  as  is  a  high 
degree  of  acidity  in  the  vagina. 

We  next  come  to  the  bimanual  examination  of  the  uterus  and 
adnexa.  This  should  first  determine  the  position,  size,  and  mobility  of 
the  uterus,  and  the  information  thus  elicited  is  often  of  the  greatest 
importance.  An  anteflexed,  undeveloped,  or  retrodisplaced  uterus  is 
frequently  associated  with  sterility,  while  restriction  in  the  range  of 
normal  mobility  points  to  adhesions,  or  contraction  of  the  broad  liga- 
ments resulting  from  a  past  infection  of  the  adnexa.  Increase  in  size 
of  the  uterus  may  be  due  to  subinvolution  or  to  the  presence  of  a  new 
growth  (fibroid).  If  the  fibroid  is  fairly  large  or  multiple  fibroids 
are  present,  little  difficulty  should  be  experienced  in  making  a  diag- 
nosis.    These  tumors  are  a  frequent  cause  of  sterility. 

Having  clearly  made  out  the  position,  size,  and  character  of  the 
uterus,  the  adnexa  are  next  palpated.  These  are  thoroughly  but  gently 
examined  for  the  presence  of  any  enlargement,  undue  tenderness,  or 
adhesions.  It  is  not  always  easy  to  distinguish  between  tube  and 
ovary,  for  both  are  often  matted  together  beyond  any  hope  of  separate 
recognition,  but  when  this  is  the  case  it  is  safe  to  conclude  that  the  tube 
is  the  primary  seat  of  disease  and  is  probably  occluded.  When  the 
condition  is  bilateral,  the  sterility  can  be  taken  to  be  absolute. 

Rectal  Examination  of  Stout  Subjects. — In  examining  very 
stout  women  and  those  with  a  small  and  tender  introitus,  a  rectal 
examination  will  many  times  succeed  where  a  vaginal  one  has  failed. 

Normal  ovaries  may  show  slight  variations  in  size  and  tenderness 
on  repeated  examination,  which  must  not  always  be  considered  as 
pathological,  for  these  changes  are  often  physiological  and  accompany 
ovulation  and  menstruation,  but  marked  and  persistent  enlargement 
of  an  ovary,  especially  when  there  is  tenderness  present,  is  usually  to 
be  taken  as  a  sign  of  disease. 

The  local  examination  should  In  all  cases  be  followed  by  a  post- 
coital one,  at  which  time  specimens  of  the  semen  deposited  by  the  male 
are  removed  from  the  vagina  and  cervix  and  studied  under  the  micro- 


68  STERILITY  AND  CONCEPTION 

scope.  Valuable  information  is  to  be  obtained  in  this  way,  but  unless 
the  technique  is  accurately  carried  out,  and  the  interpretation  made  by 
an  expert,  the  result  may  be  misleading.  When  specimens  taken  from 
the  seminal  pool  in  the  vagina  are  examined  under  the  microscope,  the 
presence  or  absence  of  spermatozoa  can  be  easily  determined.  If  such 
examinations,  made  within  one  hour  after  intercourse,  disclose  the 
presence  of  spermatozoa,  a  majority  of  these  will  usually  be  found  to 
have  lost  their  normal  motility,  or  to  have  it  very  greatly  inhibited. 
This  is  probably  due  to  the  acidity  of  the  vagina,  which  is-  generally 
supposed  to  be  inimical  to  the  life  of  the  spermatozoa,  and  the  greater 
the  length  of  time  that  has  elapsed  since  intercourse,  the  fewer  will  be 
the  number  of  live,  motile  individuals  found.  After  ten  hours  or  more, 
live  spermatozoa  are  rarely,  if  ever,  found  in  the  vagina,  but  in  the 
cervical  canal  they  live  much  longer  and  may  even  be  found  in  an 
active  state  days  after  coitus.  The  exact  period  of  life  of  the  spermato- 
zoa within  the  genital  tract  is  unknown.  For  all  practical  purposes  the 
examinations  made  in  carrying  out  the  spermatozoa  test  may  be  con- 
fined to  specimens  taken  from  the  vagina  and  cervical  canal.  If  live, 
healthy  spermatozoa  are  found  in  the  cervical  canal,  it  is  unnecessary 
to  search  the  uterine  cavity. 

Postcoital  Tests  for  Sterility. — The  postcoital  test  for  sterility 
has  many  grave  limitations,  and  for  a  full  and  comprehensive  state- 
ment of  its  value  the  reader  is  referred  to  the  writings  of  Huhner  and 
Reynolds,  who  more  than  all  others  have  done  so  much  to  illuminate 
this  hitherto  dark  page  of  gynecological  literature.  The  method  of 
obtaining  specimens  for  examination  offers  little  technical  difficulty. 
With  the  patient  in  the  dorsal  position  a  bivalve  speculum  is  intro- 
duced and  its  blades  separated,  bringing  into  view  the  receptoculum 
seminis  and  the  cervix.  A  sterilized,  narrow,  platinum  loop  is  plunged 
into  the  pool  and  the  semen  adhering  to  it  transferred  quickly  to  a 
warm  slide,  which  is  placed  on  a  warm  stage  and  examined  under  the 
microscope,  using  a  low-power  objective  (i  to  i  inch)  with  a  high- 
power  eye-piece.  Low  illumination  by  means  of  a  condenser  show 
moving  spermatozoa  quite  clearly.  The  same  method  is  used  in  taking 
specimens  from  the  cervical  canal,  except  that  the  vaginal  aspect  of  the 
cervix  is  wiped  with  sterile  cotton  and  the  superfluous  mucus  removed 
by  aspiration  with  the  Bier  cup,  which  should  be  applied  only  for  a 
moment  and  not  left  in  place  long  enough  to  draw  blood  into  the 
cervical  canal.     The  platinum  loop  is  then  gently  introduced  into  the 


ETIOLOGY— DIAGNOSIS— TREATMENT  69 

cervical  canal  and  as  gently  turned  around  several  times.  Any  bleeding 
caused  by  undue  traumatism  invalidates  the  examination. 

When  all  examinations  have  been  made,  it  is  not  always  an  easy 
matter  to  determine  their  exact  value  in  the  given  case.  If  the 
spermatozoa  found  in  the  vagina  are  normal  in  number  and  motility, 
the  fertility  of  the  male  may,  with  a  few  exceptions,  be  taken  as 
definitely  established.  When  the  spermatozoa  recovered  from  the 
cervical  canal  are  normal  in  number  and  motility,  the  question  of  the 
possibility  of  injury  by  the  female  secretions  as  being  a  cause  of  the 
sterility  is  settled  in  the  negative. 

Determining  the  Patency  of  the  Fallopian  Tubes. — Various 
ingenious  methods  for  determining  the  patency  or  otherwise  of  the 
fallopian  tubes  without  opening  the  abdomen  have  been  devised.  Direct 
probing  of  the  tubes  from  the  uterine  end,  as  well  as  the  injection  of 
solutions  through  the  tube  which  could  be  traced  by  roentgenography 
have  both  proved  unsatisfactory.  Intra-uterine  inflation  with  oxygen, 
producing,  in  the  presence  of  patent  tubes,  an  artificial  pneumoperi- 
toneum, has  been  used  to  better  advantage  and  bids  fair  to  become 
such  a  valuable  diagnostic  aid  that  I  give  the  technic  described  by 
Rubin  in  full. 

"The  technic  of  the  procedure  is  very  simple.  The  instruments 
needed  for  the  intra-uterine  injection  are  (i)  a  metal  cannula  (Keyes- 
Ultzman  type)  perforated  at  the  tip  by  several  small  apertures;  (2)  a 
tenaculum  (bullet)  forceps;  (3)  a  uterine  sound;  (4)  a  dressing 
forceps;  (5)  a  bivalve  vaginal  speculum  (Graves  type);  and  (6)  an 
oxygen  tank  connected  with  a  water  bottle.  The  rubber  stopper  is 
perforated  at  three  points,  through  which  bent  glass  connecting  tubes 
pass  into  the  bottle ;  one  of  these  glass  tubes  connected  with  the  oxygen 
tank  dips  down  below  the  water  level.  The  two  other  glass  tubes  dip 
down  for  i  or  2  inches  and  do  not  reach  the  water  level.  One  of 
these  is  attached  by  rubber  tubing  to  a  mercurial  manometer  and  the 
other  is  attached  in  the  same  way  to  the  metal  cannula.  In  order  to 
determine  the  volume  of  oxygen  gas  released  from  the  tank,  it  is 
allowed  to  pass  through  the  water  bottle  in  a  stream  of  discrete 
bubbles.  These  should  not  exceed  300  per  minute.  The  actual  amount 
per  minute  can  then  be  measured  by  displacing  from  200  to  250  c.c.  of 
water  per  minute.  The  same  rate  is  then  maintained  in  the  intra- 
uterine injection.  The  water  bottle  connected  with  the  oxygen  tank 
contains  hot  boiled  water  or  some  mild  antiseptic  solution. 

"The  cervix  is  exposed  by  means  of  the  speculum,  the  vagina  is 


70  STERILITY  AND  CONCEPTION 

carefully  wiped  clean,  and  the  cervix  is  cleansed  dry  and  painted  with 
tincture  of  iodin.  If  there  is  any  uncertainty  regarding  the  direction 
of  the  uterine  cavity,  it  may  be  determined  by  passing  the  sound.  The 
cervix  is  steadied  with  tenaculum  forceps  grasping  its  anterior  lip. 
The  oxygen,  which  has  been  released  from  the  tank  and  regulated,  is 
now  allowed  to  pass  from  the  water  bottle  through  the  glass  and  rubber 
connecting  tubing  to  which  the  metal  cannula  is  attached.  By  pinching 
the  rubber  tubing  near  the  cannula  one  can  make  sure  that  all  the  joints 
are  air  tight.  The  mercury  immediately  rises  in  this  case.  If  there  is 
some  leakage  between  the  oxygen  source  and  the  cannula,  the  pressure 
will  be  negative.  This  is  a  very  important  point  to  be  observed. 
Having  made  certain  of  the  pressure,  the  air  valves  in  the  manometer 
are  opened  and  the  catheter  is  then  inserted  into  the  uterine  cavity  to  a 
point  well  beyond  the  internal  os.  This  is  done  so  that  there  is  no 
immediate  escape  back  along  the  cervical  canal  and  out  into  the  vagina. 
The  rubber  urethral  tip,  placed  ordinarily  from  i  ^  to  2  inches  away 
from  the  cannula  tip,  is  then  fitted  into  the  external  os,  insuring  better 
obturation.  This  is  not  essential  in  the  nuUiparous  intact  cervix,  but  is 
required  in  the  irregular,  patulous  external  os  resulting  from  previous 
operations  or  from  lacerations  attending  childbirth.  The  air  valves 
are  now  closed.  Within  a  few  seconds  after  the  oxygen  enters  the 
uterine  cavity,  the  pressure  as  noted  in  the  mercury  manometer  will 
rise;  within  from  one-half  to  three-quarters  of  a  minute  in  the  patent 
cases,  the  mercury  reaches  its  maximum  point.  It  then  fluctuates  for 
a  few  seconds  or  drops  rather  sharply  from  10  to  30  points,  maintain- 
ing the  last  level  more  or  less  for  the  rest  of  the  time.  There  may  be 
a  slight  audible  escape  of  oxygen  from  the  external  os  in  the  cases  of 
patent  tubes,  but  as  a  rule  there  is  none  till  the  cannula  is  removed, 
when  slight  regurgitation  is  present. 

In  the  nonpatent  cases,  the  pressure  usually  rises  steadily  for  three- 
quarters  of  a  minute  to  a  minute  or  longer,  and  then  drops  sharply  as 
the  gas  regurgitates  into  the  vagina.  As  the  time  required  for  suf- 
ficient oxygen  to  pass  into  the  abdomen  where  it  can  be  detected  by 
fluoroscopic  examination,  is  one  and  a  half  minutes,  the  cannula  is 
not  withdrawn  till  this  time  limit  is  reached.  If  the  pressure  reaches 
200  mm.  in  one  minute,  it  is  well  to  open  one  of  the  air  valves  (needle- 
valve)  to  prevent  it  from  mounting  higher.  In  all  our  patent  cases, 
this  high  level  was  not  reached. 

The  intra-uterine  gas  pressure  has  been  a  valuable  adjunct  in 
checking  up  the  time  required  for  the  gas  to  pass  through  the  tubes 


ETIOLOGY— DIAGNOSIS— TREATMENT  71 

and  reach  the  peritoneal  cavity.  In  our  earlier  cases  we  had  decided 
on  a  three-minute  interval  as  being  necessary.  In  that  time  750  to 
850  c.c.  were  released  from  the  oxygen  tank.  We  had  no  way  of  tell- 
ing when  the  gas  actually  passed  through  the  fallopian  tubes.  The 
symptoms  were  naturally  accentuated.  The  pneumoperitoneum  was 
excessive.  A  liter  of  oxygen  was  not  necessary,  when  a  quarter  of  a 
liter  was  just  as  valuable  for  the  purposes  of  establishing  the  fact  of 
patency.  With  the  manometer  attached  to  the  new  water  bottle  we  can 
decide,  knowing  the  rate  of  flow  beforehand,  how  much  we  wish  to 
inject  into  the  abdomen.  From  the  moment  the  pressure  falls,  we 
allow  the  gas  to  flow  for  from  one-half  to  one  minute,  and  can 
estimate  the  quantity  used  with  reasonable  accuracy,  allowing  for  an 
error  of  50  c.c,  which  for  practical  purposes  is  unimportant. 

"In  the  positively  patent  cases,  the  pressure  need  not  exceed  40  mm. 
The  average  pressure  is  from  60  to  80 ;  occasionally  the  pressure  rises 
to  100  or  more  before  the  oxygen  will  pass  through  the  uterine  ostium 
of  the  fallopian  tubes.  When  the  pressure  reaches  150  or  more,  the 
likelihood  is  that  the  tube  lumen  is  closed  completely  or  stenosed,  but 
not  necessarily  in  every  case.  A  pressure  of  200  is  tolerably  certain  to 
be  due  to  closed  tubes.  Fluoroscopy,  however,  should  always  be 
employed  to  check  up  the  partially  stenosed  cases,  as  sometimes  oxygen 
will  succeed  in  escaping  into  the  abdomen,  though  the  pressure 
required  to  force  it  in  is  comparatively  high. 

"While  the  pressure  gage,  as  studied  in  the  second  series  of  thirty- 
seven  cases,  is  an  excellent  indication  of  patency  of  the  fallopian  tubes, 
it  is  well  always  to  examine  the  patient  with  the  fluoroscope.  It  occa- 
sionally happens  that  with  the  greater  pressure  a  slight  amount  of  gas 
succeeds  in  entering  the  peritoneal  cavity  and  reaching  the  subphrenic 
space  on  the  right  or  left  side,  where  it  can  be  detected  by  the  roentgen 
ray. 

"In  the  positive  cases,  that  is,  when  the  tubes  are  patent,  the  oxygen 
will  be  seen  as  a  clear  space  below  the  diaphragm,  most  often  on  both 
sides,  but  occasionally  on  one  side  only.  The  space  varies  between  one- 
quarter  to  one  inch  in  depth.  The  diaphragm  appears  as  a  transverse 
septum  above  the  dense  liver  shadow  on  the  right  side  and  over  the 
pale  stomach  margin  on  the  left.  It  is  unmistakable,  and  is  readily 
seen  when  the  patient  breathes  deeply.  In  all  our  cases  in  which  we 
have  made  roentgenograms  the  finding  was  always  confirmatory. 
Stout  patients  require  a  somewhat  greater  amount  to  allow  for  the 
density  of  the  abdominal  wall. 


72  STERILITY  AND  CONCEPTION 

"The  whole  examination  is  complete  within  five  minutes.  When 
the  minimum  volume  of  oxygen  has  been  used,  that  is,  from  i(X)  to 
150  C.C.,  the  symptoms  are  negligible.  There  is  the  slightest  discom- 
fort around  the  diaphragm,  and  slight  sticking  pains  referred  to  one 
or  both  shoulders.  The  patient  dresses  herself  and  is  able  to  go  home 
with  comfort,  and  performs  her  duties  as  though  she  had  had  a  simple 
cystoscopy.  When,  however,  more  gas  has  been  used,  the  symptoms 
may  be  somewhat  annoying.  In  such  cases,  it  is  well  for  the  patient 
to  lie  down  for  a  few  hours  on  reaching  home,  with  the  foot  of  the  bed 
elevated  (moderate  Trendelenburg  posture). 

'Tn  the  negative  cases,  that  is,  when  the  tubes  are  occluded,  no 
artificial  pneumoperitoneum  results." 

No  Infallible  Test  of  Sterility. — Cessation  of  menstruation  is 
not  to  be  considered  an  infallible  test  of  sterility.  Ovarian  tissue  may 
not  be  active  enough  to  furnish  sufficient  "hormone"  to  institute  a  com- 
plete menstrual  cycle,  yet  this  tissue  may  ovulate  and  provide  a  corpus 
luteum. 

TREATMENT   OF   STERILITY 

In  taking  up  the  subject  of  treatment  of  sterility,  we 
approach  what  is  probably  the  most  difficult  phase  of  the 
question.  Clinical  observation  and  operative  experience  have 
taught  us  more  in  this  respect  than  have  all  the  laboratory 
investigations  and  experiments  thus  far  made.  The  very  wealth 
of  material  which  these  investigators  have  accumulated  is  a 
worthy  monument  to  the  cause,  and  a  sufficient  proof  of  its 
importance.  As  so  little  is  actually  known  regarding  ovulation  and 
fecundation,  the  paucity  of  our  knowledge  regarding  sterility  and  its 
treatment  is  hardly  to  be  wondered  at.  Thus  to  a  great  extent  any 
rules  for  treatment  must  be  laid  down  on  more  or  less  empirical  lines. 

In  beginning  a  consideration  of  the  treatment  of  any  disease 
to-day,  it  is  customary  to  preface  one's  remarks  with  a  more  or  less 
extended  consideration  of  the  various  measures  by  which  the  disease 
can  be  prevented.  Only  in  a  very  limited  sense  can  this  rule  be  applied 
to  sterility.  Education  is  the  line  along  which  the  most  valuable 
results  in  prevention  will  be  achieved.  As  the  child  reaches  puberty 
he  or  she  should  be  taught  in  a  simple  and  interesting  manner  the 
wonders  of  reproduction  and  its  proper  relation  to  the  growth  of  the 
world.     Later,  a  more  general  idea  of  the  sex  relations  should  be 


ETIOLOGY— DIAGNOSIS— TREATMENT  73 

imparted,  and  with  young  people  the  nature  and  dangers  of  the 
venereal  diseases  clearly  and  strongly  dwelt  upon.  The  work  of  early 
education  in  sex  hygiene  ought  to  be  begun  by  the  parents,  but  it  is  an 
obligation  which  few  of  them  meet,  and  the  child,  in  the  majority  of 
cases,  takes  its  first  lessons,  and  only  too  often  all  succeeding  ones, 
from  play-fellows.  I  know  from  experience  that  the  role  of  teacher 
in  sex  matters  to  one's  own  children  is  a  difficult  one,  especially  with 
boys,  but  it  is  a  duty  that  should  not  be  evaded. 

For  many  good  reasons,  which  it  would  be  superfluous  to  mention 
here,  early  marriages  should  receive  every  encouragement.  One  of  the 
saddest  features  of  society  to-day  is  the  increasing  tendency  to  defer 
marriage  until  middle  age,  and  there  can  be  little  doubt  that  this  has 
much  to  do  with  out  alarmingly  high  rate  of  sterility  and  diminished 
fertility.  There  has  been  of  late  a  wholesale  commercialization  of 
nearly  everything,  and  to  this  movement  marriage  is,  I  fear,  no  excep- 
tion. 

Hygienic  Measures. — A  lack  of  proper  balance  in  diet  and 
gross  overfeeding  increase  sterility.  A  fact  often  commented  upon  by 
sojourners  among  primitive  races  is  the  enormous  stoutness  prevalent 
among  the  wives  of  the  tribal  chief,  and  they  have  commented  upon 
this  fact  as  a  curious  manifestation  of  his  idea  of  feminine  beauty,  but 
the  real  reason  underlying  this  is  that  even  primitive  man  has  recog- 
nized the  fact  that  an  abnormal  accumulation  of  fat  is  conducive  to  a 
low  rate  of  fertility,  and  he  thus  fattens  his  wives  in  order  to  keep 
down  the  number  of  his  children. 

The  cooling  and  evaporating  powers  of  outdoor  air  are  intimately 
concerned  with  health,  and  the  cool,  fresh,  morning  air  is  a  natural 
stimulus  to  activity,  clear  thinking,  deep  breathing,  and  an  active  cir- 
culation. Early  rising  is  of  great  value  to  the  individual  and  is  worthy 
of  every  encouragement.  The  outdoor  worker  has  many  advantages 
denied  the  indoor  worker  with  his  sedentary  habits  of  life.  Overfeed- 
ing, laziness,  and  luxury  are  strong  incentives  to  sex  immorality  and 
become  important  causative  factors  in  sterility. 

To  briefly  sum  up  the  question  of  the  prevention  of  sterility,  let 
me  repeat  that  youth,  good  health,  plenty  of  outdoor  exercise,  and  a 
simple  life  are  all  favorable  to  fecundity;  while  luxury  and  great 
wealth,  with  all  their  attendant  evils,  go  hand  in  hand  with  sterility. 

Leaving  this  realm  of  more  or  less  speculation  and  theory,  as 
interesting  as  it  is,  we  can  now  pass  on,  I  feel,  with  more  advantage,  to 
the  practical  one  of  the  curative  treatment  of  those  conditions  most 


74  STERILITY  AND  CONCEPTION 

commonly  associated  with  sterility  or  a  lessened  fertility.  These  will 
be  taken  up  in  separate  chapters  by  themselves,  and  dealt  with  in  a 
purely  clinical  manner.  I  shall  make  no  attempt  to  prove  my  conten- 
tions by  citing  statistics,  as  limits  of  space  and  the  desire  to  make  this 
book  readable  have  led  to  their  omission,  but  shall  rely  upon  selected 
case  histories  to  bear  me  out.  As  these  are  but  tedious  reading  at  the 
best  they  will  be  used  in  moderation  and  made  as  brief  as  will  serve 
the  purpose. 

LITERATURE 

Handler^  S.    Am.  Jour.  Surg.    Sept.,  1912. 

Brun,  a.    Policlinico.    Dec,  1919,  Feb.,  1920. 

Chetwood,  Charles  H.    Practice  of  Urology.     1921, 

Davis,  F.  P.  Impotence,  Sterility,  and  Artificial  Impregnation. 
1917. 

DuNCA>j,  J.  M.     Fecundity,  Fertility  and  Sterility.     1871. 

Englemann,  G.  J.    Jour.  A.  M.  A.    Oct.,  1901. 

Foster.    Textbook  of  Physiology.     1897. 

GiLES^  A.  E.    Sterility  in  Women.     19 19. 

HuHNER,  M.     Sterility  in  the  Male  and  Female.     1913. 

Krafft-Ebing.     Psychopathia  Sexualis.     1890. 

Marshall,  F.  H.     Physiology  of  Reproduction.     19 10. 

Reynolds,  Edward.  Fertility  and  Sterility.  Jour.  Am.  Med. 
Assn.    Vol.  LXVII. 

Rubin,  I.  C.  The  Non-Operative  Determination  of  Patency  of 
Fallopian  Tubes.     Jour.  Am.  Med.  Assn.     Sept.,  1920. 

Senator,  H.    Health  and  Disease.     1904. 

Sturmdorf,  a.    Internat.  Clinics.     1920. 

Vecki,  V.  G.    Sexual  Impotence.     1920, 


CHAPTER  IX 

GONORRHEA  AND  SYPHILIS 

Venereal  disease  and  sterility — Gonorrhea — Statistics  of  the  gonorrheal  menace — 
Case   report  of   gonorrheal   salpingitis — Syphilis 

While  opinion  may  vary  greatly  as  to  the  prevalence  of  gonorrhea 
and  syphilis,  there  can  be  little  doubt  of  the  importance  of  their  bear- 
ing on  the  question  of  sterility  and  fertility. 

Gonorrhea. — Gonorrhea,  in  marked  contrast  to  syphilis,  is 
rarely,  if  ever,  a  cause  of  antenatal  death  or  disease,  but  it  is  the  most 
common  cause  of  sterility. 

Professional  prostitution  is  the  most  frequent  source  of  venereal 
infection,  and  one  infected  prostitute  can  give  the  disease  to  many 
men  in  a  single  day,  they,  in  turn,  acting  as  infecting  agents,  often  in 
their  own  families.  Prostitution  not  only  spreads  venereal  disease  but 
strikes  at  the  very  root  of  the  family  life.  It  supplies  an  easy  and 
cheap  means  of  gratifying  the  sex  appetite  of  the  male  and  affords 
an  escape  from  the  continuous  use  of  contraceptives,  which  in  time 
becomes  intolerable  alike  to  both  parties.  Clandestine  prostitution  is  a 
very  active  factor  in  the  spread  of  venereal  disease,  and  is  practiced 
by  women  who  receive  no  money  but  indulge  in  the  pleasure  solely  as 
a  distraction,  or  as  a  means  of  showing  their  affection. 

Of  the  venereal  infections  considered  from  the  viewpoint  of  an 
etiological  factor  in  the  causation  of  sterility,  gonorrhea  is  the  most 
important.  This  disease  is  of  great  antiquity,  and  accurate  descrip- 
tions of  it  are  found  in  old  writings  as  early  as  1471  B.  C.  While 
distinctly  a  disease  of  illicit  intercourse,  it  is  frequently  acquired  inno- 
cently by  the  unsuspecting  wife,  and  marital  infections  enter  largely 
into  the  subject  of  female  sterility.  Many  of  the  infections  of  this 
class  are  contracted  on  the  bridal  night,  and  it  goes  without  saying  that 
no  man  should  be  allowed  to  marry  without  a  certificate  of  health 
from  a  reliable  source.  Examination  by  a  specialist  and  the  issuing 
of  such  a  certificate  might  well  be  one  of  the  duties  of  the  marriage 

75 


76  STERILITY   AND   CONCEPTION 

license  bureau.  Noeggerath,  years  ago,  remarked  on  the  frequency 
with  which  steriHty  follows  gonorrheal  infection. 

Coextensive  with  civilization  it  reaches  its  greatest  development  in 
large  cities,  while  rural  communities  and  primitive  peoples  enjoy  a 
comparative  immunity.  No  race  is  entirely  free  from  its  curse,  none 
have  ever  been  able  to  eradicate  or  to  even  regulate  it.  In  large  com- 
mercial centers  sexual  commerce  becomes  rife,  and  gonorrhea  breeds 
apace,  an  inevitable  result  of  certain  phases  in  social  life  that  no  nation 
has  ever  yet  been  strong  enough  to  control.  Forced  as  we  are  to  admit 
its  ever  presence,  taught  by  experience  the  futility  of  trying  to  abolish 
it,  we  can  but  aim  at  its  prevention  and  adopt  measures  to  minimize 
its  attendant. dangers. 

The  specific  cause  of  gonorrhea  was  discovered  by  Neisser  in  1879, 
who  held  this  disease  to  be,  with  the  single  exception  of  measles,  the 
most  widespread  of  all  diseases.  The  infecting  agent  is  a  micro- 
organism or,  to  speak  more  correctly,  a  group  of  micro-organisms, 
that  occur  in  pairs  or  groups  of  four  or  eight.  When  the  case  is  an 
acute  one,  these  are  easily  identified  under  the  microscope  if  properly 
stained,  but  in  chronic  cases,  their  demonstration  may  be  extremely 
difficult,  and  repeated  tests  have  to  be  made  to  exclude  the  disease.  A 
valuable  diagnostic  aid  is  the  complement-fixation  test,  which  depends 
upon  the  fixation  of  a  complement  by  a  specific  antigen  (gonococci) 
and  a  specific  antibody  (in  the  patient's  blood),  with  a  resulting  inhibi- 
tion of  haemolysis  or  positive  reaction.  The  positive  reaction  is  rarely 
obtained  until  the  third  or  fourth  week  of  the  disease,  and  persists  for 
seven  or  eight  weeks.  If  only  the  urethra  is  involved,  there  may  be  no 
reaction.  A  positive  reaction  may  be  considered  as  evidence  of  the 
presence  of  the  disease,  but  a  negative  one  does  not  necessarily  exclude 
it.  When  a  complement-fixation  test  is  at  first  positive  and  later  neg- 
ative, it  becomes  of  great  value  in  deciding  whether  or  not  a  cure  has 
been  effected. 

Norris  has  said  that  "gonorrhea  is  the  most  potent  factor  in  the 
production  of  involuntary  race  suicide,  and  by  sterilization  and  abor- 
tion does  more  to  depopulate  the  country  than  does  any  other  cause." 
It  is  hardly  an  exaggeration  to  say  that  they  are  accountable  for  more 
cases  of  sterility  than  are  all  other  diseases  put  together.  I  believe  that 
no  matter  how  high  we  estimate  the  proportion  of  sterile  marriages 
due  to  these  diseases,  especially  gonorrhea,  we  will  yet  fall  far  short 
of  the  truth. 

Where  or  when  these  diseases  first  originated  matters  but  little,  for 


GONORRHEA  AND  SYPHILIS  77 

they  are  now  widespread  in  every  civilized  clime,  as  the  elder  Keyes 
so  eloquently  said:  "They  are  found  in  the  palace  of  the  mighty,  in  the 
hovel  of  the  slave;  they  infect  the  infant  before  its  first  breath,  and 
attend  the  gray  hairs  of  age,  tottering  to  the  tomb."  Picture  to  your- 
self a  woman  of  good  physical  health  and  of  bounding  vitality,  the 
result  of  a  happy  hygienic  and  moral  life,  who,  because  her  husband 
has  infected  her  with  gonorrhea,  is,  within  a  short  time  after  her  mar- 
riage, forced  to  undergo  an  operation  necessary  to  save  her  life,  or  to 
save  her  from  years  of  chronic  invalidism,  and  after  which,  even  if  she 
entirely  recovers,  she  will  be  doomed  to  a  childless  life  for  the  rest  of 
her  days.  When  you  see  such  a  one  watching  a  neighbor's  children  at 
play,  with  the  light  of  yearning  in  her  eyes  that  can  never  be  satisfied, 
deprived  forever  of  the  priceless  boon  of  maternity,  can  she  be  blamed 
for  thinking  that  life  has  cheated  her? 

When  the  gonococcus  starts  on  its  invasion  of  the  female,  it  begins 
the  attack  on  her  genital  tract  as  a  surface  inflammation,  later  in- 
volving the  deeper-lying  tissues,  and  this  usually  by  direct  continuity. 
It  may  be  inactive  for  a  considerable  length  of  time,  only  to  take  on  a 
new  life  when  properly  stimulated.  The  gonococci  are  quick  to  invade 
gland  tissue  and  periglandular  inflammation  is  of  common  occurrence. 
In  the  glands  they  often  persist  for  a  long  time  after  the  surface  infec- 
tion has  yielded  to  treatment,  so  that  this  feature  becomes  of  consider- 
able importance  in  relation  to  prognosis. 

The  most  pointed  characteristic  of  the  disease  is  its  chronicity,  and 
it  is  from  this  standpoint  that  it  naturally  becomes  of  particular  impor- 
tance in  sterility.  Infections  of  the  vulva,  urethra,  and  vagina  yield 
readily  to  treatment,  and  here  the  disease  leaves  behind  it  no  barrier 
to  subsequent  conception,  but  with  invasion  of  the  cervix,  body  of  the 
uterus  or  adnexa,  the  story  is  quite  a  different  one,  and  sterility  is  the 
rule  rather  than  the  exception  when  these  structures  have  gone  through 
a  marked  attack  of  gonorrhea.  Infection  of  Bartholin's  and  Skene's 
glands  may  be  likewise  a  factor  in  sterility  by  causing  dyspareunia. 

The  glands  of  Bartholin,  or,  as  they  are  frequently  called,  the 
vulvo-vaginal  glands,  are  two  in  number  and  are  situated  at  the 
introitus  between  the  anterior  and  posterior  layers  of  the  triangular 
ligament,  or  at  times  just  behind  the  latter.  They  are  of  a  compound 
tubular  type,  and  under  the  stimulation  of  sexual  excitement  secrete  a 
thin,  translucent  fluid  which  gains  access  to  the  vaginal  entrance 
through  ducts  opening  just  outside  the  hymen  or  its  remains. 

In  gonorrheal  infection  of  the  cervix,  we  have  an  extremely  fre- 


78  STERILITY  AND  CONCEPTION 

quent  condition  to  deal  with,  and  one  of  far-reaching  importance  in 
sterihty.  Its  frequency  has  been  estimated  as  high  as  eighty  to  ninety 
per  cent  in  all  chronic  cases.  A  marked  tendency  of  the  infection  is  to 
remain  localized  in  the  mucosa  of  the  cervical  canal,  producing  an 
endocervicitis  with  swelling  of  the  mucosa,  and  a  hypersecretion  of 
the  cervical  glands.  This  cervical  leukorrhea  incident  to  the  inflamma- 
tion blocks  the  cervical  canal,  impeding  or  prevent  the  passage  of  the 
spermatozoa.  There  is  always  a  certain  amount  of  permanent  thicken- 
ing of  the  cervix  in  cases  of  chronic  inflammation.  When  extension  of 
the  disease  from  the  cervix  to  the  endometrium  or  body  of  the  uterus 
takes  place,  it  is  usually  at  a  menstrual  period  or  shortly  postpartum. 
But  such  extension  is  rare,  and  where  it  does  occur  spontaneous  resolu- 
tion generally  follows.  In  gonorrheal  infection  of  the  uterus  itself, 
the  disease  process  spreads  to  the  underlying  metrium,  the  uterus  is 
enlarged  and  soft,  depending  on  the  severity  of  the  infection,  and  its 
walls  are  friable  and  easily  torn. 

Gonorrheal  infection  of  the  tubes  is  alrnost  without  exception 
bilateral,  although  the  involvement  of  both  sides  may  not  be  simul- 
taneous nor  reach  the  same  stage  of  the  disease  at  the  same  time.  It 
is  quite  common  to  find  one  tube  developing  symptoms  some  days  or 
even  weeks  in  advance  of  the  other.  As  the  infection  invades  the 
tubes,  congestion  and  edema  become  marked  and  rapidly  spread  to 
all  the  layers  of  the  tube.  Gradually  the  infection  creeps  along  the 
tube,  and  as  the  distal  end  is  reached,  the  fimbriae  draw  into  the  lumen 
of  the  tube  approximating  the  peritoneal  surface,  which  is  then  agglu- 
tinated by  the  existing  inflammation.  In  this  fashion  Nature  seals  off  the 
tubes  and  keeps  the  disease  localized  in  them  so  as  to  prevent  a  wide- 
spread general  infection  of  the  peritoneal  cavity.  In  this  she  is  usually 
successful,  but  only  at  the  expense  of  the  woman's  fertility,  for  with  the 
sealing  off  of  the  tubes  comes  absolute  sterility;  the  life  of  the  woman 
has  been  saved,  but  her  power  to  conceive  is  lost  forever,  unless  it  can 
be  subsequently  restored  by  operation.  Tubal  occlusion  is,  in  the 
overwhelming  majority  of  cases,  caused  by  gonorrhea.  The  disease, 
when  it  has  thus  become  localized  in  the  tube,  may  undergo  a  gradual 
resolution  with  relief  of  symptoms,  or  go  on  to  abscess  formation, 
plunging  the  woman  into  a  state  of  chronic  invalidism  from  which  only 
a  serious  surgical  operation  can  rescue  her. 

From  a  tubal  infection  the  disease  may  spread  to  the  ovaries  by 
direct  invasion  and  produce  a  peri-oophoritis,  resulting  in  enveloping 
adhesions  with  more  or  less  thickening  of  the  capsule  of  the  ovary 


GONORRHEA  AND  SYPHILIS  79 

itself.  This  thickening  of  the  capsule  leads  to  the  formation  of  reten- 
tion cysts  of  the  follicles  and  sometimes  of  the  corpus  luteum,  though 
at  times  the  ovary  may  be  found  only  imbedded  in  adhesions  and  not  in 
itself  diseased.  When  the  infection  gains  access  to  the  substance  of  the 
ovary  it  is  usually  through  a  recently  ruptured  follicle  or  corpus 
luteum  and  the  infection  generally  then  goes  on  to  abscess 
formation.  Coincident  w^ith  this  abscess  formation  there  is  a 
general  inflammatory  involvement  of  the  entire  structure  of  the  ovary, 
leading  in  time  to  complete  destruction  of  its  function.  Mixed  infec- 
tion in  these  cases  is  quite  common,  and  the  presence  of  a  pus  tube 
is  always  a  menace  to  its  adjacent  ovary.  The  sooner  it  is  removed 
the  better. 

Statistics  of  the  Gonorrheal  Menace. — Statistics  computed 
from  reliable  sources  would  tend  to  show  that  gonorrhea  is  responsible 
for  nearly  fifty  per  cent  of  all  pelvic  inflammatory  disease  in  the 
female,  and  for  over  twenty-five  per  cent  of  the  households  on  which 
the  blight  of  sterility  has  descended.  Statistics  in  the  United  States 
show  that  from  sixty  to  eighty  per  cent  of  all  abdominal  operations 
performed  for  the  purpose  of  relieving  pelvic  disease  in  married 
women  are  the  result  of  a  contageous  disease  from  which  the  husband 
was  suffering  at  the  time  of  marriage.  Fully  eighty  per  cent  of 
infected  males  supposedly  cured  will  show  the  presence  of  gonococci 
in  their  semen,  so  that  cultivation  of  the  seminal  fluid  affords  the  best 
guarantee  that  the  individual  is  not  a  carrier.  It  is  to  be  hoped 
that  cultivation  of  this  uterine  secretion  at  the  beginning  of  menstrua- 
tion will  prove  of  equal  value  in  the  female  in  latent  cases. 

When  gonorrhea  attacks  the  female,  it  becomes  of  increasing 
importance  in  direct  proportion  to  the  extent  of  its  invasion.  If  the 
disease  remains  local  in  the  urethra  and  vagina,  and  is  cured  before  it 
has  spread  any  farther,  the  woman  suffers  little  permanent  injury. 
When,  however,  the  infection  spreads  beyond  this  point,  her  fertility, 
health,  and  even  life  are  threatened.  It  is,  therefore,  imperative  that 
active  and  efficient  treatment  should  be  begun  at  the  very  earliest  pos- 
sible stage  of  the  disease.  While  it  remains  a  local  disease  it  can  be 
best  treated  by  local  application  and  for  this  I  prefer  the  silver  prepara- 
tions used  as  follows: 

Treatment. — With  the  patient  in  the  knee-chest  position,  the 
urethra  is  flushed  with  a  twenty-five  per  cent  Argyrol  solu- 
tion. The  perineum  is  then  retracted  with  a  Sims  speculum, 
the  cervix  grasped  with  a  pair  of  tenaculum  forceps  and  drawn 


8o  STERILITY  AND  CONCEPTION 

down  within  easy  access.  The  cervical  canal  is  then  cleared 
of  mucus  and  excess  secretion  by  gentle  sponging  with  cotton- 
tipped  applicators.  Silver  nitrate  in  twenty-five  per  cent  solu- 
tion is  then  applied  to  the  canal  as  far  as  the  internal  os,  and  the 
cervix  released.  The  vagina  is  now  to  be  treated.  If  this  is  carefully 
inspected,  it  will  be  seen  that  as  a  result  of  the  knee-chest  position  and 
perineal  retraction  the  ingress  of  air  has  widely  distended  the  vagina, 
thus  giving  a  clear  view  of  all  portions  of  its  walls  and  obliterating  all 
folds  or  rugse.  The  entire  surface  of  the  vagina  is  now  seen  to  be  as 
smooth  as  the  vaginal  aspect  of  the  cervix  and  should  be  quickly  but 
thoroughly  painted  with  a  twenty-five  per  cent  solution  of  silver 
nitrate.  A  cotton  tampon  is  then  introduced  and  the  speculum 
removed.  These  treatments  should  be  given  twice  a  week  until  smears 
from  the  cervix  and  vagina  are  negative.  A  sanitary  napkin  should 
be  worn  for  twelve  hours,  when  the  tampon  is  removed  and  a  saline 
douche  given. 

When  the  disease  has  reached  the  uterus  and  tubes,  it  is  beyond 
any  treatment  with  the  hope  of  preventing  sterility.  Tubal  involve- 
ment is  bilateral,  and  to  this  rule  there  are  practically  no  exceptions. 
Absolute  sterility  results  from  occlusion  of  the  tubes.  I  have  only  seen 
one  case  in  which  conception  followed  an  undoubted  double  gonorrheal 
salpingitis: 

Mrs.  E.,  age  twenty-five  years ;  married  three  years.  Menstruation  regular 
since  thirteen  years  of  age,  five  days'  duration,  moderate  in  amount,  accompanied 
by  severe  pain.  She  had  given  birth  to  one  child  by  a  difficult  instrumental  delivery 
and  was  suffering  from  backache,  chronic  constipation,  pelvic  drag,  and  d^spareunia. 

Examination  showed  a  retroflexed  uterus  with  a  large,  tender,  prolapsed  left 
ovary.  The  uterus  was  replaced,  drawing  the  ovary  with  it  and  a  suitable  pessary 
inserted.  The  pessary  was  worn  for  one  year,  during  which  time  her  symptoms 
cleared  up  and  by  the  time  the  pessarj'^  was  removed  had  entirely  disappeared. 
She  was  seen  at  frequent  intervals  thereafter  and  at  each  examination  the  uterus 
was  found  in  normal  position  and  enlargement  of  the  ovary  had  decreased  to  about 
normal  proportion. 

The  beginning  of  the  next  year  she  had  a  marked  gonorrheal  infection. 
Repeated  vaginal  and  cervical  smears  were  positive.  She  improved  rapidly  under 
the  silver  nitrate  treatment,  but  at  the  end  of  four  weeks  both  tubes  became 
involved  and  she  ran  a  typical  course  of  double  salpingitis  and  pelvic  peritonitis 
with  elevation  of  temperature  and  pulse.  The  tubes  enlarged  very  much  in  size 
and  the  left  at  one  time  suggested  abscess  formation. 

Under  palliative  treatment  the  symptoms  subsided,  and  the  tubes  gradually 
decreased  in  size  and  tenderness.  During  the  following  year  she  was  repeatedly 
examined ;  the  left  tube  being  always  found  somewhat  tender  and  slightly 
enlarged. 

About  the  middle  of  this  year,  within  eighteen  months  after  the  beginning  of 


GONORRHEA  AND  SYPHILIS  8i 

the  gonorrhea,  she  became  pregnant  and  was  delivered  at  term  of  a  living  child. 
The  puerperium  was  uneventful. 

Syphilis. — Syphilis  should  always  receive  active  and  persistent 
treatment  in  the  interest  of  the  w^oman  herself,  but  when  she  con- 
ceives and  becomes  a  potential  mother,  a  new  factor  is  injected  into  the 
case,  and,  in  the  interest  of  her  unborn  child,  antisyphilitic  treat- 
ment becomes  of  greatly  added  importance  and  must  be  actively 
carried  out  to  guard  against  miscarriage  or  the  birth  of  a  syphilitic 
offspring.  This  should  be  begun  early  in  the  pregnancy  and  can 
only  be  administered  through  the  mother.  The  technic  of  admin- 
istration, I  feel,  belongs  to  the  field  of  urology  and  I  shall  not  take 
it  up  here;  yet  before  leaving  the  subject  I  wish  to  strongly 
emphasize  the  fact  that  as  syphilis  often  impairs  the  functioning 
of  various  organs  without  giving  rise  to  any  direct  symptoms,  and 
is  thus  many  times  overlooked,  no  stone  should  be  left  unturned  in 
ruling  it  out,  or  actively  treating  it,  in  every  case  of  pregnancy. 


LITERATURE 

Cattier.     Progres  Medical.     Paris.     192 1. 
GuiTERAs,  R.    Urology.     191 2. 

Hericourt,  J.    The  Social  Diseases.    London.     1920. 
Menge,  K.     Handb.  d.  Frauenheilkunde.     1913. 
Merklen,  Devauz  and  Desmouliere.     Paris  Medical.      192 1. 
NoGucHi.    Am.  Journ.  SyphiHs.    April,  191 7. 
NoRRis,  C.  C.    Gonorrhea  in  Women.     1913. 
Pedersen,  V.  C.    Text-book  of  Urology.    19 19. 
Praksch,  J.  K.    Die  Geschichte  d.  Ven.  Krankh.     1895. 
Sanger,  W.  W.    The  History  of  Prostitution.     1858. 
The  Social  Evil.     Report  of  the  Committee  of  Fifteen.     N.  Y., 
1902. 

Veit,  J.    Handb.  d.  Gyn.    Vol.  H.     1907. 


CHAPTER  X 

VAGINISMUS  AND  DYSPAREUNIA 

Case  report  of  vaginismus — Operative  relief  of  vaginismus — Extreme  type  of 
vaginismus — Dyspareunia  and  inflammatory  disease — Kraurosis  vulva — Urethral 
carbuncle  and  vaginal  cysts — Case  report  of  dyspareunia  due  to  vaginal  cyst — 
Treatment  of  dyspareunia. 

Proper  coitus  is  at  times  rendered  impossible  by  a  nervous 
spasm  of  the  muscles  of  the  legs  and  the  muscles  around  the 
vaginal  orifice.  Such  spasm  is  excited  by  the  slightest  approach 
on  the  part  of  the  male,  and  the  more  he  persists,  the  greater  it 
becomes.  This  condition  of  vaginismus  was  first  described  by 
Simpson  in  i860,  and  later  by  Sims  and  Emmet.  The  latter  did 
not  distinguish  it  from  dyspareunia.  The  treatment  of  this  dis- 
tressing affliction  can  most  properly  be  taken  up  under  the  two 
heads;  the  psychical  and  the  physical.  The  psychical  side  is  the 
more  difficult  one  to  deal  with,  and  attempts  to  treat  this  phase  of 
the  condition  are  nearly  always  disappointing.  Occasionally, 
however,  when  the  case  is  not  an  extreme  one,  and  the  woman 
amenable  to  reason,  matters  may  be  so  explained  to  her  that  she 
will  be  able  to  nerve  herself  up  to  the  point  where  a  successful 
intercourse  can  be  accomplished.  When  the  ice  is  once  broken, 
little  difficulty  is,  as  a  rule,  experienced  thereafter,  as  coitus  is  not 
painful.  In  such  cases  the  therapeutic  use  of  alcoholic  beverages 
will  often  prove  a  valuable  adjunct  in  helping  to  overcome  the 
spasm.    The  following  case  is  a  typical  one : 

Mrs.  C,  age  thirty-three  years.  Menstruation  began  at  the  age  of  thirteen 
years,  lasting  seven  days,  moderate  in  amount  and  accompanied  by  slight  pain.  She 
had  been  married  eleven  years  and  had  never  had  a  normal  intercourse  because  of 
marked  vaginismus.  For  a  number  of  years  past  no  attempts  at  coitus  had  been 
made.  Shortly  after  consulting  me,  at  which  time  I  explained  to  her  and  her 
husband  the  nature  of  the  case,  advising  them  as  to  means  to  overcome  it,  several 
attempts  at  coitus  took  place;  the  third  one  being  successful.  Following  this, 
the  patient  did  not  menstruate  again  and  was  delivered  at  term  of  a  living  child, 
289  days  after  the  first  successful  intercourse. 

82 


VAGINISMUS  AND   DYSPAREUNIA  83 

Operative  Relief  of  Vaginismus. — In  extreme  cases  of  vaginis- 
mus the  measures  given  above  are  of  little  avail,  and  the  treat- 
ment must  be  taken  up  entirely  from  the  physical  standpoint. 
Surgical  means  are  necessary  to  accomplish  a  cure.  For  this  a 
general  anesthetic  is  necessary  and  the  vulva  incised  so  as  to 
enlarge  the  introitus  and  at  the  same  time  to  so  relax  the  muscles 
around  the  orifice  as  to  make  its  subsequent  spasmodic  closure  to 
the  male  impossible. 

The  operative  technic  is  simple.  When  the  introitus  is  not 
unduly  small  a  median  perineal  incision  of  ample  length  is  made 
and  deep  enough  to  thoroughly  divide  the  attachment  of  the  trans- 
verse  perineal  fibers  of  the  levator  ani  muscle.  This  is  then 
sutured  in  the  opposite  direction  to  which  it  is  made,  that  is  from 
side  to  side,  and  gives  a  much-enlarged  vaginal  opening  that  will 
not  again  close  down  as  healing  takes  place.  The  separation  of 
the  muscle  fibers  gives  ample  muscular  relaxation.  When  the 
introitus  is  over  small,  two  lateral  incisions  of  the  vulva,  one  on 
either  side,  are  necessary.  These  should  likewise  be  sutured  in 
the  opposite  direction  to  which  they  are  made.  The  following 
case  was  an  extreme  type: 

Mrs.  H.,  age  thirty  years.  Menstruation  began  when  thirteen  years  old,  lasting 
four  days,  moderate  in  amount  and  accompanied  by  severe  pain.  She  is  an 
extremely  nervous  type  and  has  been  married  three  and  one-half  years,  during 
which  time  she  had  suffered  from  a  very  severe  type  of  vaginismus.  There  had 
never  been  a  satisfactory  intercourse  and  she  had  never  been  pregnant.  Her 
nervousness  had  increased  very  markedly  of  late. 

Examination,  made  with  great  difficulty,  showed  a  marked  tenesmus,  a  small 
and  rigid  introitus,  the  uterus  was  anteflexed,  the  adnexa  negative.  At  operation 
the  introitus  was  enlarged  by  two  lateral  incisions  which  were  sutured  in  the 
opposite  direction  from  which  they  were  made.  This  gave  a  normal-sized  opening 
which  subsequently  admitted  of  a  two-finger  examination  without  difficulty.  The 
first  attempt  at  intercourse  was  made  six  weeks  after  the  operation  and  was 
successful.     She  did  not  menstruate  again  and  was  delivered  at  term. 

Dyspareunia  and  Inflammatory  Diseases. — While  vaginismus 
is  a  fairly  frequent  cause  of  sterility,  dyspareunia  is,  to  my  mind, 
far  too  frequently  held  responsible  for  unfruitfulness,  and  I  cannot 
find  on  my  records  a  single  case  where  it  was  the  direct  cause  of 
the  sterility.  That  pain  on  intercourse  naturally  discourages  fre- 
quent attempts  is  quite  true,  but  the  etiological  factor  is  often  only 
transitory  and  in  time  disappears.  A  small  and  rigid  introitus 
may  require  some  time  and  patience  to  overcome,  but  is  usually  to 
be  conquered  by  persistence  rather  than  assault. 


84  STERILITY  AND  CONCEPTION 

The  inflammatory  diseases  of  the  genital  organs  are  a  common 
cause  of  dyspareunia,  and  may  even  render  intercourse  so  painful 
that  after  one  or  two  attempts,  all  further  trial  is  abandoned. 
During  the  acute  stages  of  a  gonorrheal  vulvitis  or  vaginitis,  it  is 
hardly  necessary  to  mention  that  coitus  would  be  rarely  at- 
tempted, but  after  the  acute  stage  had  subsided  a  subacute  inflam- 
mation often  remains  in  adjacent  tissues  which  persists  for  a  long 
time,  making  intercourse  extremely  painful.  The  glands  of 
Bartholin  and  of  Skene  are  common  seats  of  such  infection. 

The  glands  of  Bartholin,  or  the  vulvo-vaginal  glands,  are  two 
in  number  and  are  situated  at  the  introitus  between  the  anterior 
and  posterior  layer  of  the  triangular  ligament,  or  at  times  just 
behind  the  latter.  They  are  of  the  compound  tubular  type,  and 
are  stimulated  by  sexual  excitement;  they  secrete  a  thin,  trans- 
lucent fluid  which  gains  access  to  the  vaginal  entrance  through 
ducts  opening  just  outside  of  the  hymen  or  its  remains.  This 
secretion  acts  as  a  lubricant  during  early  intercourse,  the  glands 
becoming  less  active  with  advancing  sexual  life.  The  ducts  may 
at  times  be  involved  without  the  infection  spreading  to  the  glands. 

When  infection  of  the  glands  takes  place,  it  usually  results  in 
pus  formation,  and  as  the  duct  generally  becomes  occluded,  there 
is  no  opportunity  for  drainage,  and  the  resulting  abscess  of  the 
gland  is  extremely  tender  and  persistent.  Periodical  drainage  may 
take  place  only  to  be  followed  by  reaccumulation.  Unless  sur- 
gically treated  the  disease  may  exist  for  an  indefinite  period. 

The  proper  treatment  for  vulvo-vaginal  abscess  is  incision  and 
drainage.  The  opening  should  be  freely  made,  as  much  of  the 
gland  tissue  as  possible  curetted  away,  and  the  cavity  packed.  At 
a  subsequent  dressing  the  packing  is  removed,  the  cavity  wiped 
out  with  tincture  of  iodin  and  repacked.  This  is  continued  until 
the  cavity  is  entirely  obliterated.  In  some  cases  by  a  careful  dis- 
section the  infected  gland  can  be  removed  entire  without  rupture 
so  that  the  wound  can  then  be  treated  as  a  clean  one  and  primary 
union  secured.  This  is,  of  course,  desirable  whenever  possible. 
These  glands  have  a  strongly  resistant  power  to  other  infections 
and  gonorrhea  is  the  most  usual  infective  agent. 

Skene's  glands,  likewise  two  in  number,  but  much  smaller  than 
those  of  Bartholin,  lie  a  little  posterior  to  and  on  either  side  of  the 
meatus  of  the  urethra.  They  are  commonly  spoken  of  as  the  peri- 
urethral glands,  and  are  composed  of  small  tubules  running  par- 


VAGINISMUS  AND  DYSPAREUNIA  85 

allel  with  the  urethra  and  opening  one  on  either  side  of  the 
meatus.  Gonorrheal  infection  of  these  tissues  causes  a  lesion  very 
persistent  and  difficult  to  cure,  but  seldom  so  painful  as  to  prevent 
intercourse  unless  there  is  an  abscess  formation.  The  treatment 
consists  in  incision  and  repeated  applications  of  pure  carbolic  acid 
until  the  tubule  is  completely  destroyed. 

Kraurosis  Vulva. — Coitus  is  at  first  painful  and  later  impos- 
sible in  the  presence  of  kraurosis  vulva,  a  condition  of  the  external 
genitalia  first  described  by  Breisky  in  1885.  This  disease  is  char- 
acterized by  a  shrinking  of  the  skin  of  the  vulva  and  perineum, 
atrophic  in  nature,  and  as  a  result  of  which  the  cutaneous  folds 
become  obliterated,  leaving  the  integument  smooth,  dry,  and  with 
a  pale  shiny  appearance  quite  typical  of  the  disease.  Due  to  a  loss 
of  elasticity,  the  tissues  are  brittle  and  tear  easily  on  the  slightest 
attempt  to  open  the  vagina.  Intense  itching  and  burning  are 
often  present,  so  that  in  the  beginning,  before  the  characteristic 
pathological  changes  in  the  tissues  have  appeared,  it  is  frequently 
confused  with  pruritis.  Treatment  of  kraurosis  vulva  from  the 
point  of  view  of  the  dyspareunia  is  of  little  or  no  avail,  and 
extensive  injuries  are  likely  to  follow  from  coitus  and  childbirth. 

Urethral  Caruncle  and  Vaginal  Cysts. — A  urethral  caruncle 
can  be  the  seat  of  very  acute  pain  on  attempted  intercourse,  and 
when  present  should  be  removed.  Simple  vaginal  cysts  will  rarely 
be  found  to  be  a  cause  of  dyspareunia  and  then  only  when  in- 
flamed or  of  such  large  size  as  to  completely  block  the  vagina. 
When  either  of  these  conditions  exists,  the  cyst  should  be 
removed.  It  is  probably  best,  as  a  rule,  to  remove  all  vaginal  cysts 
of  whatever  size,  for  during  delivery  they  are  usually  ruptured,  or 
so  traumatized  as  to  break  down,  become  infected,  and  even  cause 
a  general  post-partum  infection. 

A  good  example  of  dyspareunia  caused  by  a  vaginal  cyst  was 
encountered  in  the  following  case : 

Mrs.  D.,  age,  thirty  years.  Married  five  years,  during  which  time  she  bore 
two  children,  the  last  one  two  years  ago.  After  the  birth  of  the  last  child  a 
rapidly  growing  vaginal  cyst  developed,  which,  from  its  size  and  tenderness,  had 
prevented  intercourse. 

When  I  examined  her,  the  cyst  filled  the  entire  vagina  and  had,  so  far  as  I 
could  determine,  a  high  origin  in  the  upper  vaginal  third.  Only  with  considerable 
difficulty  and  much  pain  was  it  possible  to  pass  the  tumor  with  the  finger  and 
palpate  the  cervix.  At  operation  the  cyst  was  partially  aspirated,  dissected  out,  and 
removed. 


86  STERILITY  AND  CONCEPTION 

During  the  next  two  years  intercourse  was  successfully  accomplished,  but  as 
contraceptive  methods  were  employed  the  patient  did  not  conceive.  These  were 
abandoned  the  following  year  and  conception  promptly  occurred,  the  patient  being 
delivered  at  term  of  a  living  child. 

Treatment. — In  the  treatment  of  dyspareunia  the  cause  must 
first  be  sought  for  and  when  this  is  located  and  appropriately 
treated,  the  prognosis  should  be  good.  A  very  small  introitus 
needs  to  be  thoroughly  stretched  under  general  anesthesia,  and 
when  this  is  not  sufficient  episiotomy  is  indicated.  Any  fissure, 
ulcer,  or  abrasion  around  the  vaginal  opening,  or  in  the  vagina, 
should  be  healed  before  coitus  is  again  attempted. 

Lesions  of  the  internal  pelvic  organs  are  most  liable  to  act  as  a 
cause  of  dyspareunia.  Displacements  of  the  uterus,  adhesions  of 
the  uterus  restricting  its  normal  mobility,  adnexal  disease,  pro- 
lapse of  the  ovary,  all  give  rise  to  more  or  less  painful  intercourse. 
The  appropriate  treatment  is  that  of  the  responsible  lesion  and  is 
usually  operative,  although  a  nonadherent  uterus  with  prolapsed, 
tender  ovaries  can  often  be  replaced  and  held  in  place  by  a  pessary 
and  thus  cure  the  symptoms  without  operation.  A  large,  painful 
prolapsed  ovary  lying  in  the  cul-de-sac  of  Douglas,  without  any 
accompanying  displacement  of  the  uterus,  is  not  infrequently 
found  to  be  a  cause  of  dyspareunia  and  calls  for  surgical  care. 


LITERATURE 

Allbutt,  Playfair  and  Eden.    A  System  of  Gynecology.    1906. 
Davenport_,  F,  H.    Diseases  of  Women.     1902. 
DuHRSSEN.    A  Manual  of  Gynecological  Practice.     1895. 
Emmet.     Principles  and  Practice  of  Gynecology.     1884. 
Hart  and  Barbour.    Manual  of  Gynecology.    1905. 


CHAPTER  XI 

PINHOLE  OS 

Not    always    a    cause    of    sterility— Frequently    blocked    by   mucus— Case    report. 

A  very  small  or  minute  opening  of  the  cervical  canal  does  not  by 
any  means  cause  sterility.  The  idea  so  long  advanced  and  so  per- 
sistently clung  to  by  some  illogical  minds  that  a  small  os,  even  the 
smallest  of  which  is  of  macroscopical  size  and  easily  seen  by  the  naked 
eye,  does  not  allow  the  passage  of  the  spermatozoa,  which  are  micro- 
scopical organisms,  invisible  to  the  naked  eye,  is  an  absurdity  that 
hardly  needs  any  discussion.  The  spermatozoa  have  many  times  made 
their  way  unassisted  from  the  external  genitalia  through  a  minute 
opening  in  an  unruptured  hymen,  traversed  the  length  of  the  vagina, 
finally  gained  access  to  the  uterine  cavity  through  a  pinhole  os,  and 
pregnancy  has  resulted. 

The  term  "pin-hole  os"  is  employed  in  those  cases  where 
the  diameter  of  the  external  os  is  much  less  than  normal.  However 
small,  it  is  yet  always  greater  than  the  diameter  of  any  pin.  Even  the 
most  minute  os  is  many  times  larger  than  the  opening  in  the  fallopian 
tube  at  its  uterine  end,  through  which  the  spermatozoa  readily  pass  in 
their  search  for  the  ova.  It  is  quite  true  that  the  smaller  the  cervical 
opening  the  easier  it  is  for  it  to  become  blocked  by  pathological  secre- 
tions from  the  cervical  glands,  and  thus  it  is  that  a  "pin-hole  os  tightly 
plugged  with  mucus"  may  become  a  cause  of  sterility,  A  case  in  point 
follows: 


Mrs.  S.,  age  thirty-two  years,  seven  years  married.  Menstruation  began  at  the 
age  of  twelve,  was  regular,  lasting  six  days,  scanty  in  amount,  accompanied  by 
severe  pain.  For  the  past  year  menstruation  has  been  painful.  She  has  never  been 
pregnant  and  contraceptives  have  never  been  employed. 

Examination  showed  a  small,  so-called  pin-hole  os,  tightly  plugged  with  thick, 
tenacious  mucus.  The  uterus  was  normal  in  size,  position,  and  mobility.  The 
adnexa  were  negative.     The  husband's   semen   was   normal.     At  operation  the 

87 


88  STERILITY  AND  CONCEPTION 

external  os  was  enlarged  by  two  lateral  incisions  and  sewed  up  in  the  opposite 
direction  from  which  they  were  made. 

Three  riionths  after  the  operation,  examination  showed  an  os  of  normal  size 
and  free  from  mucus  plugging.  Coitus  was  then  resumed,  and  the  patient  men- 
struated only  once  thereafter,  being  delivered  at  term  of  a  living  child  only  a  little 
more  than  one  year  after  the  operation. 


CHAPTER  XII 

CHRONIC  CERVICITIS 

Case    reports — Treatment,    medical — Operative    relief— Congenital    erosion   of   the 

cervix. 

This,  in  the  majority  of  cases,  is  a  low-grade  inflammation  which 
may  be  confined  to  the  cervical  mucosa  alone,  or,  as  is  more  often 
the  case,  extends  deeply  into  the  tissues  of  the  cervix  itself.  While 
endocervicitis  is  a  very  common  gynecological  condition,  I  cannot 
subscribe  to  the  opinion  advanced  by  many  that  eighty-five  per 
cent  of  all  women  are  thus  affected,  or  that  it  is  responsible  for 
every  female  complaint  from  leukorrhea  to  pus  tubes.  My 
experience  has  taught  me  that  it  only  becomes  an  etiological  fac- 
tor in  sterility  when  of  a  sufficient  degree  to  result  in  a  continuous 
blocking  of  the  cervical  canal  by  the  pathological  secretion  of 
mucus  from  the  cervical  glands.  The  gonococcus,  the  staphylo- 
coccus, the  streptococcus,  and  rarely,  the  colon  bacillus,  are  the 
infecting  organisms. 

In  chronic  inflammation  of  the  cervix,  the  cervical  glands  are 
in  a  state  of  overactivity,  and  their  pathological  secretions  are 
poured  out  into  the  cervical  canal  in  such  quantity  as  to  prevent 
the  passage  or  even  entrance  of  the  spermatozoa.  This  barrier 
may  be  sufficient  to  resist  all  onslaught,  even  of  the  strongest 
spermatozoa,  or  only  to  repel  the  weaker  and  less  persistent  ones. 
Reynolds  has  most  painstakingly  shown  that  only  the  most  vigor- 
ous spermatozoa  seem  able  to  penetrate  even  a  slight  mucus  bar- 
rier, either  bunting  themselves  to  death  against  the  obstruction 
or  after  penetrating  it  but  a  short  distance  become  enmeshed 
much  as  does  a  fish  in  a  gill  net,  and  there  destroy  their  vitality 
in  ineffectual  efforts  at  further  progress.  If  the  cervical  canal  can 
be  kept  free  of  this  mucus  plug  for  a  sufficient  length  of  time  to 
allow  of  connection  before  it  refills,  the  spermatozoa  may  attain 
their  end  and  conception  result.  The  following  case  is  fairly 
typical  of  what  I  mean : 

89 


90  STERILITY  AND  CONCEPTION 

Mrs.  S.,  twenty-six  years  of  age,  had  been  married  four  years,  and  although 
extremely  anxious  for  children,  had  never  been  pregnant.  Menstruation  was 
normal  and  there  was  no  evidence  of  any  adnexal  disease.  The  uterus  was  normal 
in  size,  position,  and  mobility.  She  had  always  suffered  from  a  profuse,  cervical 
leukorrhea  which  had  never  been  treated. 

On  examination  within  one  hour  after  intercourse,  normal,  active  spermatozoa 
were  present  in  the  vagina  in  plenty.  The  cervical  canal  was  found  tightly  plugged 
by  an  accumulation  of  thick,  stringy  mucus.  When  the  enlarged  cervix  was  forcibly 
compressed  between  the  blades  of  a  bivalve  speculum,  fully  a  dram  of  thick 
mucus  exuded.  Subsequently  under  a  light  anesthetic,  the  cervix  was  slowly  but 
thoroughly  dilated  and  freed  of  all  accumulated  mucus.  Conception  occurred  before 
the  time  for  the  next  menstruation,  and  she  was  delivered  at  term  of  a  living  child. 


Fig.  13. — Bier  Cup  in  Place  over  Cervix. 

Treatment,  Medical. — When  the  cervicitis  is  not  active  enough 
to  quickly  refill  the  canal  with  mucus,  the  line  of  treatment  carried 
out  in  the  above  case  vv^ill  usually  suffice.  Often,  however,  the 
cervical  glands  are  so  active  that  the  mucus  plug  speedily  reforms, 
and  in  these  the  cervical  inflammation  has  to  be  treated  for  some 
time  before  the  canal  can  be  kept  free  of  mucus  long  enough  for 
conception  to  take  place.  The  best  method  of  treatment  is  active 
hyperemia  secured  by  means  of  the  Bier  cup  applied  over  the 
cervix  for  a  ten-minute  period  three  times  a  week.  Very  often 
this  causes  a  complete  disappearance  of  the  mucus  plug  in  a  few 
months  with  a  subsidence  of  all  the  symptoms  due  to  the  cer- 
vicitis, even  the  sterility,  as  shown  in  the  following  case : 

Mrs.  T.  B.,  thirty-seven  years  of  age.  Menstruation  regular.  She  had  been 
married  fourteen  years,  during  which  time  she  had  given  birth  to  two  children  by 


CHRONIC  CERVICITIS  91 

normal  labors ;  the  last  one  was  born  eleven  years  ago.  Since  then  two  pregnancies 
were  interrupted  at  six  and  eight  weeks,  the  last,  five  years  before  I  saw  her.  From 
this  last  abortion  she  had  developed  a  profuse  and  persistent  cervical  leukorrhea 
which  had  been  treated  at  various  times  but  without  relief. 

On  examination  the  cervix  was  seen  to  be  large  and  its  canal  tightly  blocked 
with  a  thick,  opalescent  plug  of  mucus.  The  uterus  was  normal  in  size,  position, 
and  mobility,  and  the  adnexa  negative.  The  cervical  condition  was  treated  by 
artificial  hyperemia  by  means  of  the  Bier  cup  twice  a  week  for  two  months.  The 
excessive  amount  of  mucus  present  at  first  rapidly  decreased  under  this  treatment 
and  was  replaced  by  the  normal,  glairy,  cervical  secretion.  One  month  after  the 
last  treatment  she  conceived  and  was  delivered  at  term  of  a  living  child. 


Operative  Relief. — When  the  infection  of  the  cervix  is  too 
extensive  to  yield  to  the  measures  above,  as  is  often  the  case 
where  gonorrhea  is  the  etiological  factor,  resort  must  be  had  to 
operative  measures,  and  the  infected  cervical  tissue  with  its  glands 
reamed  out.  Even  amputation  of  the  cervix  may  be  necessary  in 
extreme  cases. 

Congenital  erosion  of  the  cervix,  though  of  uncommon  occur- 
rence, is  usually  accompanied  by  sterility.  Here  the  profuse  cer- 
vical leukorrhea  which  is  nearly  always  present  keeps  the  canal 
permanently  blocked. 


CHAPTER  XIII 

LACERATION  OF  THE  CERVIX 

Case  report — 'Conditional  sterility — Gravity  theory — Case  reports — Relative  sterility 

and  habitual  abortion. 

When  there  has  been  a  solution  in  continuity  of  the  cervix  at 
all  extensive,  marked  pathological  changes  in  the  cervical  tissues 
arise  unless  a  primary  repair  is  performed.  These  changes  may  be 
the  result  of  either  infection  or  chronic  venous  stasis  and  affect 
the  fertility  of  the  vv^oman  in  a  number  of  different  ways.  Bilateral 
tears  cause  a  turning  out  of  the  cervical  lips  (ectropion),  and  this 
everted  surface  of  the  cervical  portion  of  the  endometrium  then 
lies  in  the  vagina  instead  of  in  the  cervical  canal.  Here  the  con- 
tinuous irritant  action  of  the  vaginal  secretion,  which  is  foreign  to 
it,  keeps  the  tissues  in  a  constant  state  of  irritative  inflammation. 
The  result  of  chronic  cervicitis,  from  whatever  cause,  is  a  tend- 
ency to  permanently  obstruct  the  cervical  canal  by  the  excessive 
secretion  poured  out  by  the  cervical  glands.  In  cases  of  ectropion 
the  cervix  should  be  restored  to  its  normal  relations  with  the 
vagina  by  means  of  a  bilateral  repair.  For  the  extensively  infected 
cervix,  amputation  is  the  best  treatment. 

Mrs.  W.  L.  R.,  thirty-eight  years  of  age,  married  five  years.  Menstruation 
began  at  twelve  years,  always  regular,  lasting  seven  days,  moderate  in  amount  and 
painless.  Conception  had  occurred  promptly  after  marriage,  resulting  in  a  normal 
delivery  at  term.  After  this  she  had  two  abortions  in  the  early  months  of 
pregnancy.  With  the  last  one  the  interruption  had  occurred  at  three  months,  two 
years  before  she  came  under  my  care.  With  this  abortion  the  cervix  had  been 
badly  lacerated  and  was  not  repaired.  From  this  time  on  she  suffered  from  a 
profuse  leukorrhea,  and  did  not  again  conceive. 

Examination  showed  a  lacerated  and  greatly  enlarged  cervix;  the  canal  being 
tightly  plugged  with  mucus.  The  uterus  was  normal  in  size,  position,  and  mobility, 
and  the  adnexa  showed  no  evidence  of  disease.  At  operation  the  cervix  was 
repaired,  within  the  first  three  months  thereafter  conception  occurred  and  was 
followed  by  normal  delivery  at  term  of  a  living  child.     Another  similar  case  was : 

Mrs.  R.  P.,  thirty-one  years  old.  Menstruation  began  at  twelve,  always  regular, 
lasting  eleven  days,  profuse  in  amount  and  with  severe  pain.     She  had  been  mar- 

92 


LACERATION   OF  THE   CERVIX  95 

ried  for  six  years  and  was  delivered  o£  her  only  child  three  years  ago.  Since 
then  there  had  been  no  further  pregnancies  and  she  suffered  constantly  from  back- 
aches, pelvic  drag,  menorrhagia,  and  dysmenorrhea. 

Examination  showed  a  large  bilateral  lacerated  and  eroded  cervix  with  a  pro- 
fuse cervical  leukorrhea  plugging  the  canal.  The  uterus  was  enlarged  and  retro- 
flexed  but  not  adherent.  The  adnexa  were  negative.  At  operation  on  August  4, 
1920,  in  St.  Bartholomew's  Hospital,  the  uterus  was  curetted  and  the  cervix  repaired, 
after  which  the  uterus  was  replaced  manually  and  a  pessary  inserted.  This  treat- 
ment resulted  in  a  cure  of  all  her  symptoms ;  she  conceived  three  months  later  and 
was  delivered  at  term  of  a  living  child. 

Conditional  Sterility. — From  a  purely  mechanical  point  of 
view,  laceration  of  the  cervix  is  far  oftener  a  cause  of  conditional 
sterility  than  is  commonly  taught. 

Herman,  of  London,  after  special  study  of  this  subject,  re- 
ported three  cases  in  1902,  where  a  repair  of  the  cervix  was 
promptly  followed  by  the  birth  of  a  living  child.  All  three  patients 
had  been  subject  to  repeated  abortions  without  other  assignable 
cause  before  the  repair  was  performed.  He  said,  "Seeing  that  the 
cervical  canal  is  kept  closed  during  pregnancy  by  the  firm  con- 
traction of  its  muscular  fibers,  so  that  the  uterine  contents  are  not 
expelled,  although  the  uterus  is  contracting  continually  through- 
out pregnancy,  and  that  the  first  step  in  the  process  of  labor  is 
the  inhibition  of  these  muscular  fibers,  it  seems  to  be  reasonable 
to  suppose  that  weakening  of  the  cervix  by  extensive  laceration 
might  lead  to  premature  expulsion  of  the  contents  of  the  uterus; 
and  that  if,  in  such  a  case,  the  cervix  uteri  were  strengthened  by 
repair  of  the  laceration,  possibly  abortion  might  be  prevented." 

His  operations  were  performed  upon  healthy  women  who  com- 
plained of  nothing  except  that  they  had  repeatedly  failed  to  carry 
their  children  to  full  term,  and  in  whom  the  only  cause  discover- 
able for  the  repeated  abortions  was  a  laceration  of  the  cervix.  It 
can  be  granted  then  that  the  cervical  canal  is  kept  closed  during 
pregnancy  by  the  tonic  contraction  of  its  muscular  fibers,  and 
whatever  interferes  with  the  proper  maintenance  of  this  closure 
predisposes  to  an  interruption  of  the  pregnancy.  I  am  of  the 
opinion  that  this  early  interference  is  often  favored  by  gravity, 
where  the  unsupported  ovum  drags  upon  its  uterine  attachment 
until  sufficient  separation  occurs  to  cause  its  death  and  final  expul- 
sion, and  that  the  continual  contractions  normally  occurring  in 
pregnancy  are  not  to  be  considered  as  the  sole  cause. 

Cervical  lacerations  associated  with  marked  chronic  cervicitis 
may  prevent  conception,  as  has  been  previously  pointed  out,  bul 


94  STERILITY  AND  CONCEPTION 

when  conception  in  such  cases  occurs  there  is  nothing  in  the  mere 
presence  of  the  lacerations  to  prevent  the  pregnancy  going  on  to 
a  favorable  termination,  with  one  exception,  and  this  is  when  the 
laceration  extends  completely  through  the  internal  os.  The  uter- 
ine cavity  is  then  left  with  a  widely  dilated  opening  below,  through 
which  the  growing  ovum  prolapses  by  gravity.  Especially  is  this 
true  in  the  more  active  class  of  patients  who  are  much  on  their 
feet.  As  the  ovum  enlarges  it  lacks  the  support  of  the  closed 
internal  os  below  and  gradually  sinks  into  the  cervical  canal. 
From  now  on,  if  the  external  os  is  not  closed  sufficiently  to  hold 
it  back,  it  presents  at  the  vagina,  into  which  it  gradually  descends. 
This  downward  progress  of  the  ovum  tugs  at  its  attachment  in 
the  uterine  cavity  above  and  gradually  loosens  it,  eventually 
resulting  in  a  complete  detachment.  Occasionally  when  the  ex- 
ternal OS  is  sufificiently  closed  to  prevent  this,  the  ovum  becomes 
attached  to  the  cervical  canal,  resulting  in  a  partial  or  complete 
cervical  pregnancy.  In  such  cases  abortion  generally  results, 
although  a  few  cases  of  cervical  pregnancy  have  been  recorded 
that  went  to  term. 

One  of  the  first  cases  which  I  had  an  opportunity  to  carefully 
observe  seems  to  me  to  present  strong  evidence  in  favor  of  the 
gravity  theory  and  I  therefore  give  the  history  in  detail : 

Mrs.  J.  D.  was  twenty-six  years  of  age  and  had  been  married  two  years,  during 
which  time  she  had  given  birth  to  two  children.  The  last  labor  was  a  difficult 
instrumental    delivery,    at   which    time   she    sustained    an    extensive    cervical    tear. 

Examination  showed  a  three-months  pregnant  uterus  in  normal  position  with 
an  absence  of  any  adnexal  involvement.  The  cervix  was  large  and  soft  with  an 
extensive  laceration  on  the  left  side  extending  through  the  internal  os,  so  that  the 
examining  finger  could  readily  feel  a  considerable  area  of  the  bulging  ovum.  There 
had  already  been  several  slight  hemorrhages,  and  when  seen  she  was  flowing  quite 
freely.  For  two  days  she  was  kept  in  bed  and  not  allowed  on  her  feet  at  any 
time.  She  was  then  allowed  the  freedom  of  her  room.  Two  weeks  later  there  was 
a  return  of  the  bleeding,  only  not  so  profuse. 

Examination  at  this  time  showed  that  the  uterus  had  continued  to  enlarge,  but 
the  ovum  was  found  protruding  through  the  cervix,  reaching  about  two  inches  down 
into  the  vagina.  She  was  again  placed  in  bed,  when  the  bleeding  stopped  as  before, 
and  in  two  days  a  reexamination  showed  that  the  ovum  had  retracted  back  into  the 
uterine  cavity.  Several  days  later,  believing  herself  free  from  any  further  danger, 
she  disregarded  my  advice  and  indulged  in  a  prolonged  shopping  tour  downtown. 
On  her  way  home  she  began  to  bleed  freely,  and  an  examination  made  shortly  after 
she  reached  home  showed  a  large  proportion  of  the  ovum  extruded  from  the  cervix 
into  the  vagina.  That  evening  she  expelled  the  gestation  with  intact  membranes. 
The  cervical  tear  was  subsequently  repaired  and  she  carried  the  next  pregnancy 
uneventfully  to  term  and  was  delivered  of  a  living  child. 


LACERATION  OF  THE  CERVIX  95 

Another  case  of  the  same  nature  was : 

Mrs.  E.  S.,  thirty-six  years  of  age,  during  her  married  life  had  given  birth  to 
eight  children;  the  last  one  a  large  postmature  child  delivered  with  forceps.  At 
this  time  she  sustained  an  extensive  anterior  laceration  of  the  cervix  through  the 
internal  os  and  a  complete  perineal  laceration  as  well.  Following  this  delivery 
there  had  been  two  abortions  at  three  months  for  no  known  reason,  and  each  one 
was  preceded  by  a  prolonged  period  of  bleeding.  No  examination  during  these 
pregnancies  had  been  made,  but  I  feel  certain  from  the  history  that  their  causation 
was  the  same  as  in  the  case  of  Mrs.  J.  D.  above  mentioned.  The  cervix  and 
perineum  were  repaired,  and  the  next  pregnancy  was  carried  to  a  successful  issue. 

Relative  Sterility  and  Habitual  Abortion. — Complete  lacera- 
tion of  the  cervix  will  be  found  to  be  a  more  or  less  frequent  cause 
of  relative  sterility,  responsible  for  a  certain  number  of  cases  of 
habitual  abortion.  The  proper  treatment  is,  of  course,  the  radical 
repair  of  the  cervix,  as  carried  out  in  the  cases  above  cited. 

Herman  does  not  state  the  periods  at  which  the  abortions 
occurred  in  his  cases,  but  in  mine  they  were  all  early,  during  the 
first  four  months,  at  a  time  when  contractions  of  the  uterus  are 
not  as  frequent  as  in  the  later  months.  We  find  in  many  cases 
of  pregnancy  that  during  the  later  months,  both  the  external  and 
internal  os  are  wide  open,  so  that  one  finger,  and  sometimes  two, 
can  easily  be  passed  through  the  cervical  canal  into  the  uterus, 
yet  they  go  on  to  term,  but  in  the  early  months  of  pregnancy  such 
a  condition,  in  my  experience,  invariably  terminates  in  abortion 
if  the  patient  is  not  kept  off  her  feet  until  the  placenta  is  formed 
and  firmly  attached. 

If,  as  Herman  says,  "it  is  reasonable  to  suppose  that  weaken- 
ing of  the  cervix  by  extensive  laceration  tends  to  a  premature 
expulsion  of  the  contents  of  the  uterus,"  then  it  seems  to  be  highly 
probable  that  complete  laceration  of  the  cervix  through  the 
internal  os,  which  leaves  an  open-doored  uterus,  can  well  be  a 
frequent  cause  of  habitual  abortion  in  the  early  months  of  preg- 
nancy. 

This  condition  may  be  easily  overlooked  when  the  tear  in  the 
external  os  has  united  or  has  been  previously  repaired.  Where 
complete  laceration  is  suspected,  the  cervix  should  be  dilated  suf- 
ficiently to  disclose  the  condition  of  the  internal  os.  It  is  not 
sufficient  to  repair  alone  the  lower  vaginal  portion  of  the  cervix, 
but  care  must  be  taken  to  bring  accurately  together  the  upper  uterine 
portion  as  well,  so  as  to  restore  the  integrity  of  the  internal  os. 


96  STERILITY  AND  CONCEPTION 

I  believe  that  laceration  through  the  internal  os  probably  inter- 
rupts almost  as  many  pregnancies  as  laceration  of  the  external  os 
prevents.  If  pregnancy  is  already  present  when  the  patient  is 
first  seen,  it  may  be  possible  to  carry  her  safely  beyond  the  danger 
point  by  postural  treatment.  This  danger  point  is  passed  as  a  rule 
when  the  placenta  becomes  firmly  attached  or  about  the  fourth 
month,  but  all  danger  may  not  be  over  until  the  fetus  has  turned 
and  presents  by  the  vertex,  the  head  then  acting  as  a  ball-valve, 
keeping  the  uterine  cavity  closed. 

The  treatment,  as  already  stated,  consists  in  keeping  the 
patient  in  bed  until  all  danger  has  passed.  Much  can  often  be 
accomplished  in  this  way,  as  the  horizontal  position  causes  the 
ovum  to  retract  into  the  uterine  cavity,  relieving  the  pull  on  its 
attachment,  and  further  separation  is  thus  prevented.  If  the 
symptoms  of  threatened  abortion  return  when  she  again  gets  out 
of  bed,  the  same  treatment  should  be  repeated  and  persisted  in 
for  a  longer  period. 

Few  patients,  however,  will  appreciate  the  true  condition  of 
affairs  or  agree  to  such  a  prolonged  rest  in  bed  unless  extremely 
anxious  for  a  child.  It  most  of  these  cases  of  complete  laceration 
a  correct  diagnosis  has  never  been  made,  and  syphilis  is  usually 
advanced  as  the  cause  of  the  repeated  abortions.  In  my  experi- 
ence, habitual  abortion  in  the  early  months  of  pregnancy  is  seldom 
of  syphilitic  origin. 


LITERATURE 

Child,  Jr.,  C.  G.    Diseases  of  Women.     1909. 
Herman.    Laceration  of  the  Cervix  a  Cause  of  Habitual  Abortion. 
Joum.  Obstet.  and  Gyn.  of  the  British  Empire.    Sept.,  1902. 


CHAPTER  XIV 
ANTEFLEXION   OF   THE  UTERUS 

Mutilating  operations  of  no  value — Intrauterine  stems  a  pernicious  practice — Proper 
development  of  uterus — Examination  and  treatment  under  anesthesia — Cervical 
stenosis  and  faulty  surgery. 

Under  this  heading  are  generally  included  the  various  degrees 
of  anteflexion,  from  the  very  small,  infantile  type  of  uterus  up  to 
the  anteflexed  uterus  of  normal  size,  but  these  varying  types  have 
a  vastly  different  bearing  on  the  question  of  sterility.  For  many 
years  we  failed  to  appreciate  the  true  significance  of  anteflexion, 
considering  it  as  a  displacement  of  the  uterus.  In  the  light  of  our 
present  knowledge  it  should  be  looked  upon  rather  as  an  error 
in  development,  or  possibly  better  a  condition  of  arrested  develop- 
ment. The  anteflexed  uterus  in  the  grown  woman  is  a  persistence 
of  the  infantile  type  of  organ,  in  other  words,  a  uterus  that  has 
never  reached  maturity.  Such  a  uterus  we  find  very  frequently 
associated  with  sterility,  it  is  true,  but  the  sterility  is  not  due,  as 
is  so  often  taught,  to  the  angle  of  flexion  which  exists  between  the 
cervical  canal  and  the  uterine  cavity  in  this  type  of  uterus.  In  all 
probability  it  is  a  result  of  the  immaturity  of  the  organ,  undevel- 
oped and  therefore  unfitted  to  take  on  the  burden  of  maternity. 
When  pregnancy  occurs  for  the  first  time  in  such  a  uterus,  early 
abortion  very  often  results.  The  small,  immature  organ  is  unable 
to  keep  pace  with  the  growing  fruit  which  it  contains,  and  inter- 
•  ruption  occurs  usually  at  some  period  between  the  sixth  week  and 
the  third  month.  In  these  cases,  it  will  often  be  found  that  as  a 
result  of  this  miniature  labor,  the  uterus  has  taken  on  a  consider- 
able development,  and  it  is  not  at  all  unusual  for  subsequent  exam- 
inations to  show  that  the  previously  undeveloped  uterus  has 
grown  to  the  dignity  of  adult  size,  even  though  the  angle  of  flexion 
may,  and  often  does,  remain.  In  fact,  the  angle  of  flexion  fre- 
quently persists  through  the  entire  life  of  the  uterus,  and  such 
anteflexion  is  often  encountered  in  women  who  had  borne  many 

97 


98  STERILITY  AND  CONCEPTION 

children.  The  added  development  which  the  immature  uterus 
acquires  as  a  result  of  this  miniature  labor  is  usually  sufficient  to 
enable  it  to  carry  the  second  pregnancy  to  term.  While  the 
infantile  uterus  is  usually  a  sterile  type,  the  anteflexed  uterus  is 
not  necessarily  so. 

Mutilating  Operations. — The  many  mutilating  operations  with 
which  the  anteflexed  uterus  has  been  attacked  is  a  sad  chapter  in 
surgical  gynecology,  and  much  mischief  has  likewise  resulted 
from  the  use  of  the  so-called  intra-uterine  stems.  Were  it  not- for 
the  recent  revival  of  this  pernicious  method  of  treatment  the 
subject  might  be  dismissed  without  further  comment;  but  so  much 
malpractice  has  been  perpetrated  by  this  contrivance  in  the  hands 
of  those  apparently  ignorant  of  the  first  principles  of  gynecological 
pathology  that  I  trust  some  good  may  be  done  by  quoting  the 
views  held  by  Emmet  on  this  subject.  More  than  thirty-five  years 
age  he  wrote  as  follows : 

"Unfortunately,  members  of  the  profession  are  frequently 
advocating  the  use  of  the  stem  pessary,  regardless  of  the  experi- 
ence of  those  who  have  gone  before  them,  until  they,  in  turn,- 
learn  that  they  have  not  been  wiser  in  their  day.  As  soon  as  the 
true  condition  comes  to  be  appreciated,  the  use  of  the  intra-uterine 
stem  will  be  abandoned  as  a  most  irrational  instrument.  Experi- 
ence will  at  last  teach  every  one  that  no  permanent  benefit  is  ever 
derived;  and  that  sooner  or  later,  in  almost  every  case,  mischief 
will  result  from  the  use  of  the  instrument." 

Cases  bearing  out  the  truth  of  what  Emmet  wrote  so  long  ago 
are  coming  to  our  attention  again,  so  that  it  is  now  no  unusual 
experience  to  meet  with  the  pathetic  case  of  the  young  woman 
in  whom  the  use  of  the  stem  pessary  has  resulted  in  an  infection 
involving  the  uterus  and  tubes.  This  may  have  even  necessitated 
a  pan-hysterectomy.  At  the  best  she  has  been  deprived  of  all 
hope  of  maternity,  which  was  her  heart's  desire,  and  with  intelli- 
gence enough  to  understand  the  situation  can  hardly  be  blamed 
for  her  feelings  of  bitter  resentment  at  the  way  she  has  been 
maltreated. 

Proper  Development  of  Uterus. — If  treatment  designed  to 
relieve  the  sterility  in  these  cases  is  to  be  of  avail,  it  must  be 
directed  toward  the  proper  development  of  the  uterus,  and  this 
can  best  be  brought  about  by  putting  the  organ  through  as  close 
an  imitation  of  a  miniature  labor  as  possible.     This  is  the  way 


ANTEFLEXION   OF  THE  UTERUS  •       99 

Nature  cures  these  cases,  and  the  closer  we  follow  her  lead  the 
greater  will  be  our  reward. 

Examination  and  Treatment  under  Anesthesia. — Under 
a  general  anesthetic  the  cervix  is  slowly,  carefully,  but  thoroughly 
dilated;  the  uterine  cavity  is  then  explored,  and  measurements  taken 
of  its  depth  from  internal  os  to  fundus  for  future  comparison.  The 
curette  should  not  be  used,  as  the  undeveloped  uterus  is  often  deficient 
in  endometrium,  and  when  curetted  will  occasionally  cease  menstru- 
ating altogether  and  undergo  a  premature  atrophy.  The  uterme 
cavity  should  now  be  tightly  packed  with  a  narrow  strip  of  iodoform 
gauze,  brought  out  through  the  cervix  into  the  vagina.     I  say  tightly 


Fig.  ,14. — Anteflexion  of  the  Uterus  (Pryor). 


packed  because  the  object  of  this  treatment  is  to  stin.ulate  contractions 
by  introducing  a  foreign  body  (the  gauze)  into  the  uterus,  thus  lead- 
ing to  a  greater  muscular  development  and  a  further  increase  in  size. 
Iodoform  gauze  is  best  used  because  it  will  remain  in  the  uterus  and 
vagina  the  necessary  length  of  time  without  becoming  foul.  The 
patient  so  treated  should  have  the  fluid  extract  of  ergot  administered 
in  thirty-drop  doses  every  three  hours  during  the  first  three  days  after 
operation,  until  severe  uterine  contractions  are  noted,  or  the  physio- 
logical tolerance  of  the  drug  reached.  On  the  fourth  day  the  gauze 
packing  is  removed.  At  this  time,  in  those  patients  who  have  had 
severe  uterine  colic  attending  the  treatment,  it  is  not  unusual  to  find 
that  the  bulk  of  the  uterine  packing  has  been  expelled  into  the  vagina. 
Time  and  again  I  have  found  this  to  be  the  case.     Many  of  these 


loo     .  STERILITY  AND  CONCEPTION 

patients  complain  very  bitterly  of  the  severe  pain  accompanying  this 
treatment,  and  those  who  have  always  suffered  from  severe  dysmenor- 
rhea often  say  that  the  pain  is  in  excess  of  any  they  ever  had  with 
their  menstruation,  so  that  this  should  be  explained  to  them  in  advance 
as  being  a  part  of  their  treatment.  Morphine  or  codein  can  be  given 
if  the  pain  becomes  unbearable.  When  this  treatment  has  been  carried 
out  once  or  twice,  careful  measurement  of  the  uterine  cavity  will 
generally  show  that  it  is  markedly  increased  in  depth,  and  occasionally 
we  are  able  by  a  bimanual  examination  to  make  out  an  actual  increase 
in  the  size  of  the  uterus.  When  dysmenorrhea  has  previously  existed, 
it  will  usually  be  cured,  and  conception  often  promptly  result. 

Cervical  Stenosis  and  Faulty  Surgery. — Much  of  the  surgery 
that  has  been  done  in  cases  of  cervical  stenosis,  so  called,  and  ante- 
flexion of  the  uterus,  has  been  of  "the  family  doctor"  variety.  It  is 
a  habit  with  many  general  practitioners  to  advise  "a  little  stretching 
and  scraping"  to  every  would-be  mother  that  consults  him,  and  many 
of  these  are  brides  of  only  a  few  months,  his  idea  being  that  the  sper- 
matozoa cannot  enter  a  small  cervical  canal  or  turn  the  corner  of  an 
angle  of  flexion.  He  shows  entirely  too  little  respect  for  Nature  and 
sadly  underestimates  the  ability  of  this  clever  organism.  The  fre- 
quency with  which,  even  to-day,  cervical  dilitation  and  the  correction 
of  an  anteflexion  are  advised  as  a  cure  for  sterility  is  a  sad  reflec- 
tion on  our  teaching. 

That  the  angle  of  flexion  is  in  itself  a  barrier  to  conception  is  not 
true;  and  it  is  encouraging  to  see  that  this  erroneous  opinion  is 
advanced  less  frequently  now  than  was  the  case  fifteen  or  twenty  years 
ago.  Special  study  by  an  ever-increasing  number  of  competent  ob- 
servers has  brought  into  the  light  of  day  many  facts  that  were  hitherto 
shrouded  by  darkness  in  the  night  time  of  gynecological  investigation. 
Difficulty  in  defining  the  symptoms  has  also  been  greatly  lessened  since 
anteflexion  has  been  ruled  out  of  the  category  of  displacements  and 
become  properly  recognized  as  an  error  in  development. 

LITERATURE 

Emmet.     Principles  and  Practice  of  Gynecology.     1884. 

Hart  and  Barbour.     Gynecology.     1905. 

Pryor,  W.  R.     Gynecology.     1903. 

Roberts,  C.  H.    Gynecological  Pathology.     1901. 


CHAPTER  XV 

RETRODISPLACEMENTS  OF  THE  UTERUS 

Anatomy  of  the  uterus  and  adnexa — Ligamentous  attachments  of  uterus — Mechan- 
ism of  displacements — Pelvic  diaphragm — Gravity  and  position  of  the  uterus — 
Arrested  uterine  development  • —  Classification  of  retrodisplacements  —  Case 
reports — Habitual  abortion  due  to  congenital  retrodisplacements  of  uterus — 
Case  reports^Postpartum  retrodisplacements — Case  reports — Operative  cor- 
rection of  retrodisplacements — Treatment  of  retrodisplacements — The  use  of 
the  pessary. 

There  has  existed  in  the  past,  and  still  exists,  such  a  wide 
difference  of  opinion  regarding  the  part  played  by  retrodisplace- 
ments of  the  uterus  in  sterility  and  fertility  that  any  work  dealing 
with  the  subject  would  be  woefully  lacking  without  some  attempt 
being  made  to  reconcile  these  conflicting  opinions.  To  do  this  it 
becomes  necessary  to  consider  at  some  length  the  anatomy  and 
physiology  of  this  organ. 

The  uterus,  more  so  probably  than  any  other  organ  in  the 
body,  rests  in  a  state  of  unstable  equilibrium,  undergoing  frequent 
changes  in  position  consequent  upon  a  continually  shifting  center 
of  gravity  and  constant  physiological  changes  in  the  adjacent  vis- 
cera. Being  of  small  bulk,  less  than  three  ounces  in  weight,  and 
attached  to  highly  elastic  structures  within  a  cavity  large  enough 
to  admit  of  considerable  latitude  of  movement,  it  is  not  hard  to 
realize  that  under  unfavorable  circumstances  even  a  very  slight 
cause  may  suffice  to  produce  a  displacement.  In  order  to  better 
understand  how  the  normal  balance  is  maintained,  let  us  turn  for 
a  moment  to  the  anatomy  of  the  uterus  and  its  adjacent  structures. 

Anatomy  of  the  Uterus. — With  the  woman  in  the  erect  pos- 
ture, the  pelvis  occupies  an  oblique  position  with  regard  to  the 
trunk  of  the  body,  being  at  an  angle  of  sixty  to  sixty-five  degrees 
with  the  ground  on  which  she  stands.  Within  the  pelvis  lies  the 
uterus,  parallel,  or  nearly  so,  to  the  horizon.  Its  fundus  is  directed 
forward  and  rests  with  its  face  on  the  posterior  aspect  of  the 
bladder,  to  which  it  is  united  by  a  reflection  of  peritoneum.  Above, 


I02 


STERILITY  AND  CONCEPTION 


the  uterus. does  not  reach  the  plane  of  the  inlet,  and  its  long  axis, 
from  the  fundus  to  the  cervix,  lies  in  front  of  the  axis  of  the  pelvis, 
but  the  two  are  parallel  and  form  with  the  long  axis  of  the  body 
trunk  an  angle  varying  from  70  to  100  degrees.  The  cervix  is 
directed  backward  towards  the  hollow  of  the  sacrum,  perpen- 
dicular to  the  axis  of  the  vagina.  The  external  os  lies  at  the  level 
of  the  upper  margin  of  the  symphysis  pubis,  and  in  a  frontal  plane 
passing  through  the  spinal  ischiatical. 

This  relative  position  between  uterus  and  pelvis  remains 
pretty  constant,  though  considerable  variation,  within  physio- 
logical limits,  may  occur.  For  example,  as  the  bladder  fills  it  rises 
in  the  pelvis,  carrying  the  fundus  upward;  a  marked  degree  of 


Fig.  15. — Normal  Position  of  Uterus. 

overdistention  pushes  the  fundus  backward  and  swings  the  cervix 
forward.  Thus,  as  the  fundus  approximates  the  promontory  of 
the  sacrum,  the  uterine  axis  becomes  nearly  one  with  that  of  the 
pelvis.  When  the  bladder  empties  the  fundus  swings  forward 
again,  while  the  cervix  goes  back,  and  the  uterus  as  a  whole  sinks 
to  its  former  position.  An  overdistended  rectum  crowds  the  uterus 
forward  and  may  even  flex  the  cervix  upon  the  fundus,  at  times 
elevating  the  organ  well  out  of  the  pelvis.  As  the  body  is  bent 
forward,  the  uterus  may  change  somewhat  its  position  in  the 
pelvis,  which  it  tends  to  leave,  approaching  the  abdominal  cavity. 
In  the  dorsal  position  the  uterus  moves  back  a  certain  distance 
toward  the  hollow  of  the  sacrum,  though  normally  this  occurs  to 
only  a  slight  degree.     The  highest  point  of  the  fundus  does  not 


RETRODISPLACEMENTS  OF  THE  UTERUS  103 

extend  above  the  pelvic  brim,  and  the  normal  non-pregnant  uterus 
is  always  entirely  within  the  pelvis.  As  the  uterus  is  one  of  the 
most  movable  organs  in  the  body,  it  necessarily  follows  that  it 
does  not  always  maintain  a  constant  and  unalterable  position. 

The  fundus  and  cervix  form  with  one  another  an  obtuse  angle 
equal  to  about  160  degrees,  but  many  variations  occur  without 
constituting  a  sufficient  departure  from  normal  to  be  classed  as 
pathological.  The  uterine  axis  is  usually  straighter  in  parous 
women  than  in  those  who  have  never  borne  children,  though  this 
is  by  no  means  the  rule.  We  frequently  find  persisting  in  women 
who  have  borne  a  number  of  children  a  markedly  anteflexed 
uterus.  They  are  seldom  found  to  suffer  from  dysmenorrhea, 
so  common  a  symptom  in  nullipara  with  anteflexion. 

Ligament  Attachments  of  Uterus. — We  come  now  to  a  con- 
sideration of  the  means  by  which  this  support,  allowing  as  it  does 
of  such  extensive  changes  in  position,  is  accomplished.  If  we  stop 
for  a  moment  at  this  point  and  consider  the  other  organs  in  the 
body,  we  find  that  they  are  all,  without  exception,  suspended  by 
ligaments  or  ligament-like  structures;  the  lungs,  the  brain,  the 
heart  are  all  held  in  place  in  this  manner.  Nature's  method  of 
supporting  organs  is  by  suspension  and  by  suspension  alone,  for 
only  in  this  way  is  it  possible  to  protect  them  from  injury  or 
impairment  of  function  that  would  result  from  sudden  changes  in 
position  of  the  body,  did  they  occupy  a  fixed  and  immovable 
position.  The  uterus  is  no  exception  to  this  rule.  Indeed,  there 
is  no  other  organ  in  the  body  comparable  with  it  in  size  that  has 
so  many  and  so  strong  ligaments.  Were  it  not  for  this  efficient 
cradle-like  suspension,  probably  few  pregnancies  would  survive 
nine  months  of  continuous  jolting.  In  addition  to  the  suspending 
ligaments  there  are  certain  supporting  structures  which  undoubt- 
edly exert  a  strong  sustaining  influence.  Much  of  the  cervical 
support  is  probably  derived  from  attachment  to  the  vagina,  and 
to  the  connective  tissue  between  it  and  the  bladder,  as  well  as  the 
recto-uterine  muscles  running  to  the  lateral  walls  of  the  rectum, 
and  to  the  sacrum. 

The  principal  supporting  structures  of  the  uterus  I  would 
enumerate  then  as:  (i)  The  broad  ligarnents;  (2)  the  uterosacral 
ligaments;  (3)  the  round  ligaments;  (4)  the  transverse  cervical 
ligament;  (5)  the  cervicovaginal  insertion  with  the  fascial  attach- 
ment to  the  bladder. 


I04 


STERILITY  AND  CONCEPTION 


The  two  broad  ligaments  are  reflections  of  peritoneum  and 
pass  from  the  pelvic  wall  and  floor  across  the  pelvis,  enclosing 
between  their  layers  the  round  ligaments,  ovarian  ligaments,  and 
fallopian  tubes,  together  with  the  associated  blood  vessels  and 
nerves.  They  are  analogous  to  the  mesentery  of  the  small  intes- 
tines, serving  the  same  purpose  for  the  uterus  and  its  appendages, 
i.e.,  to  help  hold  4;hem  in  position  and  to  transmit  their  nutrient 
vessels.  The  superior  free  border  represents  the  summit  of  the 
plication  which  turns  around  the  tube  and  descends  by  a  sinuous 
course  toward  the  sides  of  the  pelvis,  its  outer  extremity  lying 
external  to  the  distal  end  of  the  tube,  forming  a  sharp,  strong  fold, 
the  infundibulo-pelvic  ligament  carrying  the  ovarian  vessels. 


Fig.  1 6. — Retroflexion  of  the  Uterus. 


The  two  utero-sacral  ligaments  are  enclosed  in  the  recto- 
uterine folds  of  the  peritoneum  running  to  the  lateral  walls  of  the 
rectum,  and  to  the  sacrum.  This  fold  of  peritoneum  lies  between 
the  uterus  in  front  and  the  rectum  behind,  forming  the  floor  of 
the  pouch  of  Douglas.  The  lateral  boundaries  of  this  pouch  are 
the  two  utero-rectal  folds  that  enclose  between  their  layers 
bundles  of  fibrous  and  muscular  tissue,  passing  from  the  cervix  to 
their  insertion,  partly  in  the  walls  of  the  rectum  and  partly  in  front 
of  the  sacrum.  They  arise  as  flat,  rounded  cords  from  the  pos- 
terior walls  of  the  uterus,  and  contribute  efficient  aid  to  the  sup- 
port of  its  cervical  segment.  These  ligaments  are  of  variable 
thickness,  well  defined  in  some  cases,  and  in  others  barely  per- 
ceptible.    When  well  developed  they  are  of  considerable  value  in 


RETRODISPLACEMENTS  OF   THE   UTERUS  105 

holding  the  cervix  up  in  the  hollow  of  the  sacrum,  preventing  its 
forward  and  downward  displacement.  The  two  round  ligaments 
are  larger,  stronger,  and  more  consistent  in  their  development. 
They  consist  of  connective  tissue  and  smooth  muscle  fiber,  with 
some  nutrient  vessels  and  nerves,  and  arise  from  each  horn  of  the 
uterus  in  front  of  and  just  below  the  tube.  Their  mode  of  origin 
is  by  a  fanshaped  base,  narrowing  down  to  a  rounded  cord  as  the 
ligament  develops.  It  is  not  unusual  to  encounter  an  anomalous 
origin  in  one  or  both  ligaments,  the  point  of  attachment  being 
farther  forward,  nearer  the  cervix,  and  I  have  at  times  found  them 
coming  oE  as  far  forward  as  the  waist  of  the  uterus.  This  low 
attachment  is  an  important  point  with  relation  to  posterior  dis- 
placements, and  is  an  anomaly  frequently  found  in  the  congenital 
displacements. 

The  round  ligaments  are  about  five  inches  long  and  one- 
quarter  of  an  inch  thick,  and  pass  from  their  origin  at  the  uterus 
forward  and  outward  between  the  folds  of  the  broad  ligaments  to 
the  lateral  pelvic  wall.  Gradually  decreasing  in  size,  they  enter 
the  internal  abdominal  ring,  pass  along  the  inguinal  canal,  and  out 
at  the  external  ring  to  be  finally  lost  in  the  labia  majora.  The 
action  of  the  round  ligaments  is  to  hold  the  fundus  forward. 

The  transverse  cervical  ligaments  consist  of  bands  of  firm, 
fibrous  tissue  which  forms  a  distinctive  part  of  the  visceral  layer 
of  the  pelvic  fascia.  They  arise  in  the  neighborhood  of  the  ischial 
spines  and,  passing  through  the  cellular  tissue  of  the  pelvis,  are 
attached  to  the  sides  of  the  cervix  and  to  the  vaginal  vault.  Unlike 
the  true  uterine  ligaments  they  have  no  special  peritoneal  cover- 
ing. According  to  some  anatomists,  they  form  a  part  of  the 
sheath  of  the  uterine  arteries,  which  reach  the  uterus  at  about  the 
same  level.  The  most  recent  investigations  would  seem  to  estab- 
lish the  fact  that  these  fascial  bands  are  of  considerable  impor- 
tance in  maintaining  the  position  of  the  cervix.  The  cervico- 
vaginal  insertion,  together  with  the  fascial  attachment  to  the 
bladder  (the  utero-vesical  ligaments),  affords  a  certain  amount  of 
support  to  the  uterus,  though  just  how  much  is  problematical. 

That  these  ligaments  are  the  sole  support  of  the  uterus  is 
amply  proved  by  investigation,  and  that  the  uterus  derives  its 
support  in  any  way  from  underlying  structures  is  absolutely  false, 
notwithstanding  past  and  even  present  assertions  to  the  contrary. 
The  old  idea  of  perineal  support  probably  arose  from  the  fact  that 


io6  STERILITY  AND   CONCEPTION 

as  laceration  of  the  perineum  was  so  often  associated  with  pro- 
lapse of  the  uterus,  it  was  taken  for  granted  that  the  perineum 
acted  as  a  sort  of  prop  under  the  uterus  to  hold  it  in  place.  Those 
who  formulated  this  theory  neglected  to  take  into  consideration 
the  fact  that  it  is  only  when  the  perineum  is  partly  torn  that  pro- 
lapse occurs,  that  when  it  is  completely  destroyed  prolapse  seldom 
results.  Furthermore,  prolapse  in  nulliparous  women  with  an 
absolutely  intact  perineum  is  not  unusual,  and  retrodisplacements 
abound  in  this  class  of  patients.  We  are  therefore  led  inevitably 
to  the  conclusion  that  the  perineum  is  not  an  essential  support  to 
the  uterus. 

When  the  perineal  muscles  are  torn  or  greatly  overstretched 
certain  new  mechanical  elements  are  introduced  that  may  become 
important  factors  in  contributing  towards  a  displacement. 

Pelvic  Diaphragm. — The  pelvic  diaphragm,  limiting  the 
abdomino-pelvic  cavity  below,  as  the  abdominal  diaphragm  limits 
it  above,  is  probably  of  great  importance.  It  is  also  not  infre- 
quently lacerated  during  labor,  the  tear  extending  through  its 
anterior  portion.  It  is  a  musculo-fascial  structure  of  great  elas- 
ticity, composed  of  two  layers,  a  deep  (superior)  fascial  layer,  and 
a  superficial  (inferior)  muscular  layer.  The  superior  layer  is  a 
part  of  the  visceral  layer  of  the  pelvic  fascia,  which  arises  from 
the  white  lines,  and  seems  to  form  a  part  of  the  inner  wall  of  the 
ischio-rectal  fossa.  The  inferior  layer  is  formed  by  the  coccygeus 
muscles.  These  are  comparatively  weak  muscles,  morphologically 
the  homologs  of  the  strong  tail-wagging  muscles  of  the  lower 
vertebrates.  In  the  human  species  they  are  not  so  well  developed 
and,  as  Paramore  has  shown,  have  assumed  a  very  different  func- 
tion, that  of  enabling  the  pelvic  floor  to  meet  variations  in  intra- 
abdominal pressure.  These  muscles  are  thrown  into  a  state  of 
contraction  during  defecation,  and  whenever  a  sudden  increase  in 
intra-abdominal  pressure  occurs,  as  in  coughing,  sneezing,  and 
during  violent  muscular  exertion.  Thus  they  sustain  the  pelvic 
viscera  against  forces  tending  to  drive  the  viscera  through  the 
pelvic  outlet.  The  levator  ani  has  a  long  continuous  line  of  attach- 
ment to  the  pubic  wall,  from  the  back  of  the  symphysis  pubis  in 
front  to  the  ischial  spine  behind,  its  fibers  pass  more  or  less 
obliquely  downwards  and  inwards  to  meet  those  of  the  opposite 
side,  or  to  become  attached  to  the  walls  of  the  uretha  and  vagina, 
to  the  median  aponeurosis  between  the  vagina  and  the  anus,  and 


RETRODISPLACEMENTS  OF  THE  UTERUS  107 

to  the  coccyx.  Muscles  and  fascia  are  closely  blended,  the  latter 
being,  in  fact,  the  muscles  aponeurosis.  The  lower  surface  of  the 
levator  ani  is  covered  by  the  thin  anal  fascia. 

The  tissues  comprising  the  pelvic  diaphragm  are  closely  united 
to  the  urethra  in  its  lower  half,  to  the  cervix,  to  the  vaginal  vault, 
and  posteriorly  to  the  rectum  and  sacrum. 

As  the  levator  ani  is  a  comparatively  feeble  muscle  with  a  thin 
fascial  edge,  its  central  portion  is  frequently  lacerated  by  the 
advancing  head  in  labor,  resulting  in  a  gradually  developing  recto- 
cele,  which  by  its  constant  drag  finally  pulls  the  cervix  into  the 
axis  of  the  vagina,  throwing  the  fundus  back  when  the  intra- 
abdominal pressure  acting  on  the  anterior  wall  of  the  fundus 
eventually  drives  the  uterus  farther  back  into  a  position  of  per- 
manent retrodisplacement. 

The  principal  suspensory  structures  of  the  uterus  are  the 
utero-sacral  ligaments,  holding  the  cervix  up  in  the  hollow  of  the 
sacrum,  and  the  round  ligaments  holding  the  fundus  forward. 
The  part  taken  by  the  round  ligaments  is  a  most  important  one, 
but  only  at  certain  times  are  they  called  upon  to  actively  enter 
into  the  support  of  the  uterus.  They  are  attached  to  the  fundus, 
and  serve  to  guide  and  limit  its  excursions.  Pulling  always  for- 
ward by  virtue  of  their  attachment  at  the  external  inguinal  ring, 
it  is  easily  seen  how  they  help  to  counteract  any  tendency  to  a 
retrodisplacement.  Largely  muscular  in  structure,  they  possess 
in  common  with  other  muscles  the  power  of  undergoing  hyper- 
trophy, a  fact  clearly  established  in  pregnancy,  where  they  enlarge 
and  elongate,  keeping  pace  with  the  hypertrophy  of  the  uterus. 
In  pregnancy  they  hold  the  fundus  forward  as  it  rises  into  the 
abdominal  cavity,  and  after  delivery,  involuting  hand  in  hand  with 
the  uterus,  they  pull  the  fundus  back  in  safety  to  its  anterior  posi- 
tion in  the  pelvis.  When  for  any  reason  the  uterus  reaches  a  low 
enough  level  in  the  pelvis  to  bring  the  uterine  attachment  of  the 
ligaments  below  the  pelvic  attachments,  the  round  ligaments 
become  truly  "suspensory,"  and  strongly  resist  any  further  down- 
ward progress.  Any  condition  that  weakens  or  stretches  the  liga- 
ments of  the  uterus,  or  increases  the  weight  of  the  uterus,  tends 
to  the  production  of  a  displacement. 

From  a  consideration  of  the  foregoing,  it  will  readily  be  seen 
that  any  attempt  to  define  the  position  of  the  uterus  must  take 
into    account    its    various    tissue    relations    to    the    neighboring 


io8  STERILITY  AND  CONCEPTION 

structures.  As  the  muscular  and  connective  tissues  of.  the  vagina 
are  directly  continuous  with  the  muscular  and  connective  tissues 
of  the  uterus  and  of  the  muscular  tissue  and  fascia  of  the  pelvic 
diaphragm,  it  can  be  easily  understood  why  these  should  be  con- 
sidered as  important  factors  in  uterine  support. 

The  investing  peritoneum  of  the  free  portion  of  the  uterus  is 
continuous  on  either  side  with  the  broad  ligaments,  with  the  blad- 
der anteriorly,  and  the  rectum  posteriorly,  but  it  is  doubtful  if  this 
peritoneum  acts  in  any  way  as  a  supporting  factor. 

To  the  upper  segment  of  the  cervix  are  attached  the  strongest 
supporting  structures,  to  the  lower  segment  practically  none, 
while  to  the  fundus  are  attached  only  the  round  ligaments.  Thus 
are  the  body  and  vaginal  portions  left  comparatively  free  to 
develop  very  considerable  changes  in  position,  but  as  the  upper 
cervical  segment  remains  the  pivotal  point,  neither  can  undergo 
any  marked  change  in  position  without  a  corresponding  change 
of  the  other ;  when  the  fundus  moves  posteriorly,  the  cervix  comes 
forward  into  the  axis  of  the  vagina,  only  to  go  back  again  to  its 
normal  position,  perpendicular  to  the  vaginal  axis,  when  the 
fundus  once  again  comes  forward.  This  upper  cervical  segment, 
though  constituted  by  virtue  of  its  many  attachments  a  fixed 
point,  so  to  speak,  is  by  no  means  immovable,  but,  to  the  contrary, 
has  a  wide  range  of  mobility  under  perfectly  normal  conditions. 
How  dependent  the  uterus  may  be  on  neighboring  viscera  for 
its  support  is  problematical,  but  I  see  no  reason  to  believe  that 
they  act  other  than  to  help  to  change  its  position  within  normal 
limits.  We  frequently  meet  with  a  uterus  crowded  into  an  extreme 
anterior  position  against  the  symphysis  by  a  rectum  overdistended 
with  feces,  and  likewise  a  retroverted  uterus  held  back  in  the  hol- 
low of  the  sacrum  by  an  overdistended  bladder.  The  uterus 
readily  replaces  as  soon  as  the  mechanical  factor  is  removed.  This 
rectal  condition  never  causes  a  permanent  displacement,  but  habit- 
ual overdistention  of  the  bladder  is  an  important  etiological  factor 
in  displacements  and  one  not  so  generally  appreciated  as  it  should 
be.  Even  the  most  casual  dilettante  in  vaginal  examination  will 
readily  diagnose  a  pelvis  full  of  feces,  while  a  bladder  containing 
twenty  or  more  ounces  of  urine  may  entirely  escape  his  notice. 
Frequently  have  my  students  made  a  diagnosis  of  retroversion  for 
which  they  advised  operative  correction  when  the  passage  of  a 
catheter  resulted  in  the  immediate  restoration  of  the  uterus  to 


RETRODISPLACEMENTS  OF  THE   UTERUS  log 

normal  position.  Women  are  prone  to  neglect  the  function  of 
urination,  and  I  have  often  seen  a  temporary  retrodisplacement 
that  might  have  in  time  become  permanent  corrected  in  a  few 
months  by  a  more  frequent  emptying  of  the  bladder. 

Gravity  and  Position  of  Uterus. — Gravity  has  much  to  do  with 
the  position  of  the  uterus,  and  any  marked  increase  in  its  normal 
weight  must  be  taken  into  consideration.  Though  of  subordinate 
importance  to  the  other  factors  mentioned,  it  nevertheless  enters 
into  the  etiology  of  many  retrodisplacements,  particularly  the 
postpartum  ones.  As  a  rule  the  traction  of  the  ligaments  is 
stronger  than  the  effect  of  gravity,  so  that  th%  position  of  the 
uterus  does  not  change  with  changes  in  position  of  the  woman. 
But  when  the  ligaments  are  lax  and  the  uterus  large,  as  in  the 
postpartum  state,  prolonged  lying  in  the  dorsal  position  may  easily 
produce  a  retrodisplacement.  The  influence  of  gravity  then  varies 
directly  with  the  weight  of  the  uterus  and  the  relaxation  of  its 
supporting  structures. 

I  have  purposely  omitted  thus  far  any  reference  to  intra- 
abdominal pressure  as  an  essential  factor  in  maintaining  the  nor- 
mal support  of  the  uterus,  because  I  do  not  believe  that  it  enters 
the  question  except  on  the  negative  side.  That  it  influences  the 
position  of  the  uterus  under  certain  conditions,  just  as  do  the 
rectum  and  bladder,  cannot  be  denied.  The  support  of  the  uterus 
is  maintained  by  its  connection  with  adjacent  tissues;  its  position 
only  is  modified  by  gravity,  neighboring  viscera,  and  intra- 
abdominal pressure. 

The  posterior  deviations  of  the  uterus  from  normal  are  gen- 
erally known  as  retroversion  and  retroflexion.  The  difference 
between  the  two  is  largely  one  of  degree,  and  though  retroflexion 
implies  a  change  of  form  as  well  as  position,  the  retroversion  of 
the  morning  may  be  converted  into  a  retroflexion  by  evening. 
The  location  of  the  angle  of  flexion  is  generally  at  the  level  of 
the  internal  os.  There  are,  besides  these,  two  additional  types 
important  enough  to  justify  special  mention  :  the  retroposed  ante- 
flexion, where  retroversion  is  combined  with  flexion  over  the 
anterior  surface;  and  the  anteposed  retroflexion,  where  antever- 
sion  with  flexion  over  the  posterior  surface  exists.  The  former  of 
these  combinations  is  not  unusual  and  occurs  when  a  rigid  ante- 
flexion falls  or  is  drawn  by  adhesions  into  retroversion.  The  lat- 
ter is  of  extreme  rarity  and  follows  the  operative  replacement  of 


110  STERILITY  AND  CONCEPTION 

an  inflexible  retroflexion,  where  the  angle  of  flexion  was  not  cor- 
rected at  the  time  of  operation. 

Classification. — For  the  purpose  of  classification,  the  retro- 
displacements  may  be  considered  from  several  different  points  of 
view.  Those  that  are  acquired  should  be  separated  from  those 
that  are  of  congenital  origin.  The  influence  of  the  development 
of  the  organ  itself  is  essentially  different  in  those  originating  dur- 
ing fetal  life  and  childhood  from  those  acquired  in  later  life.  Also 
is  the  treatment  at  times  widely  different.  There  are  further  dis- 
placements caused  by  the  pressure  of  tumors  from  without,  and 
some  that  result  directly  from  trauma. 

A  retroflexion,  even  of  long  years'  standing,  does  not  neces- 
sarily destroy  the  normal  flexibility,  but  when  this  has  been  lost, 
the  flexion  must  be  corrected  at  the  same  time  as  the  displace- 
ment. Displacements  of  the  uterus  are  considered  pathological 
only  when  they  become  more  or  less  permanent.  Limitation  of, 
or  obstruction  to,  normal  mobility  is  characteristic  of  retrodis- 
placement  of  the  organ. 

There  can  be  little  practical  use  in  laying  down  any  particular 
angle  to  characterize  retroversion  or  retroflexion,  or  the  differ- 
ence between  the  two.  The  retroverted  fundus  seldom  becomes 
permanently  retroverted  until  it  reaches  the  posterior  pelvic  wall. 
After  this  there  can  be  little  or  no  doubt  regarding  the  nature  of 
the  displacement.  Definitions  of  different  degrees  of  retroversion 
and  retroflexion  might  be  of  some  practical  value  in  certain  indi- 
vidual cases,  if  all  authorities  defined  these  differences  in  the  same 
way.  As  they  do  not  do  this,  it  seems  to  me  that  any  such 
definition  is  useless  and  of  purely  academic  interest.  However, 
in  order  to  have  some  standard  to  go  by,  I  shall  assume  that  retro- 
version of  the  uterus  exists  when  the  axis  of  the  uterine  body 
forms  an  obtuse  angle  with  the  axis  of  the  pelvic  inlet;  and  retro- 
flexion when  the  posterior  uterine  wall  is  bent  upon  itself.  Both 
are  permanent  inclinations  of  the  fundus  backward,  but  in  retro- 
flexion there  is  a  marked  change  in  the  relations  between  the 
fundus  and  the  cervix,  that  is,  a  change  of  form  as  well  as  of  posi- 
tion. If  the  uterus  be  displaced  posteriorly  beyond  its  normal 
range  of  mobility  and  does  not  spontaneously  return  to  position, 
the  displacement  becomes  pathological.  The  uterus,  though  par- 
ticularly mobile  at  all  times,  is  often  forced  into  extreme  retro- 
version  by  an   overdistended  bladder.     It   should,   nevertheless. 


RETRODISPLACEMENTS  OP  THE  UTERUS  ill 

promptly  return  to  its  normal  position  as  soon  as  the  distended 
bladder  is  emptied.  Abnormal  mobility  often  leads  to  permanent 
retrodisplacement,  of  which  it  is  a  necessary  antecedent,  and 
depends  upon  the  general  relaxation  of  all  of  the  uterine  supports. 

It  is  not  only  interesting  then,  but  important,  to  discriminate 
between  physiological  retrodisplacement  and  pathological  retro- 
displacement.  As  we  have  seen,  the  former  is  produced  by  certain 
physiological  changes  in  the  surrounding  viscera;  but  it  should  be 
borne  in  mind  that  an  extreme  degree  of  retrodisplacement,  such 
as  retroversion,  is  never  physiological,  and  whenever  found  is  to 
be  considered  pathological. 

There  is  a  type  of  retrodisplacement  important  enough  to 
justify  special  mention,  and  which  is  considered  as  congenital. 
This  is  more  often  seen  in  the  form  of  flexion  than  of  version. 
Being  the  result  of  a  faulty  development,  it  is  usually  accom- 
panied by  errors  in  the  development  in  other  parts  of  the  genital 
tract  as  well.  The  commonest  of  these  is  a  short  anterior  vaginal 
wall  which  has  an  important  bearing  on  treatment;  for  until  this 
is  lengthened  sufficiently  to  allow  the  cervix  to  swing  back  into  the 
hollow  of  the  sacrum,  the  fundus  cannot  be  made  to  remain  for- 
ward with  any  degree  of  success. 

I  cannot  agree  with  those  who  take  the  stand  that  so  long  aa 
a  congenital  retrodisplacement  causes  no  symptoms,  it  does  not 
call  for  treatment.  My  experience  has  been  that  symptoms  always 
develop  in  this  type  of  case  sooner  or  later,  and  that  by  the  time 
these  manifest  themselves  more  or  less  permanent  changes  have 
occurred  in  the  uterus  itself  which  might  have  been  avoided  had 
it  been  earlier  restored  to  its  normal  position.  The  sooner  after 
puberty  that  such  a  displacement  is  corrected,  the  greater  is  the 
chance  of  the  uterus  developing  into  a  normal  organ.  Congenital 
retrodisplacement  is  not  such  a  rare  condition  as  one  might  be  led 
to  believe  from  the  slight  attention  paid  to  it  in  the  literature. 
Various  reporters  have  found  it  present  in  from  thirteen  to 
twenty-five  per  cent  of  all  cases  of  backward  displacement.  The 
congenital  shortness  of  the  vagina  is  often  found  where  there  is  a 
combination  of  retroversion  with  flexion — the  above-mentioned 
retroposed  anteflexion. 

An  arrest  in  development  of  the  uterus  leads  to  a  persistence 
of  the  infantile  type,  that  is,  extreme  anteflexion.  This  original 
shortness  of  the  anterior  vaginal  wall  brings  the   small  uterus 


112  STERILITY   AND  CONCEPTION 

lower  under  the  bladder,  so  that  where  habitual  distention  of  the 
bladder  in  normal  cases  causes  only  slight  retroversion,  in  the 
cases  of  congenital  shortness  of  the  vagina  the  combination  of 
retroversion  with  anteflexion  is  met  with  comparatively  often.  It 
has  also  been  observed  that  senile  involution  of  the  genital  organs 
is  frequently  accompanied  by  a  shortening  of  the  vagina,  which, 
as  the  capacity  of  the  bladder  remains  unaltered  or  even  increased, 
frequently  leads  to  retroversion  of  the  uterus  in  elderly  women. 

Relaxation  of  all  the  attachments  of  the  uterus  is  by  far  the 
commonest  of  the  anatomical  causes  leading  to  retroversion  and 
retroflexion,  A  uterus  that  has  been  retrodisplaced,  even  though 
but  for  a  short  time,  becomes  at  once  stable  again.  The  organ 
may  undergo  repeated  returns  to  normal  for  weeks  or  months 
before  it  finally  comes  to  a  permanent  state  of  retroflexion.  This 
is  the  class  of  cases  that  yields  such  happy  results  to  the  pessary 
treatment.  Posterior  flexion  of  the  uterus  is  seldom  ever  moref 
acute  than  a  right  angle. 

Retrodisplacements  of  the  uterus  are  among  the  most  common 
pathological  affections  of  the  female  generative  organs,  and  have 
much  to  do  with  sterility  and  lessened  fertility,  but  it  is  next  to 
impossible  to  give  even  approximately  accurate  statistics  regard- 
ing their  frequency  and  effect  upon  procreation. 

From  a  perusal  of  the  foregoing,  it  should  be  quite  evident  that 
to  define  just  what  constitutes  a  displacement  of  the  uterus,  of  a 
sufficient  degree  to  be  considered  abnormal,  presents  in  many 
cases  considerable  difficulty.  As  a  general  rule  displacement  of 
the  uterus  need  only  be  considered  as  pathological  when  such  dis- 
placement is  more  or  less  permanent.  The  normal  range  of  mobil- 
ity of  the  uterus  may  be  limited,  or  even  obstructed,  or  its  range 
of  mobility  may  be  very  markedly  increased.  Such  limitation  or 
obstruction  is  usually  due  to  inflammatory  changes  in  the  sur- 
rounding tissues,  or  to  the  presence  of  neoplasms  in  the  uterus 
itself,  and  is  decidedly  permanent.  Increase  in  the  range  of 
mobility  is  invariably  due  to  overrelaxation  of  the  normal  attach- 
ments of  the  uterus,  and  thus  may  be  only  temporary.  The  knee- 
chest  position,  properly  taken,  may  in  time  correct  a  displacement 
of  this  kind  by  relieving  the  tension  on  the  overstretched  supports, 
thus  giving  them  a  chance  to  regain  their  normal  tone.  It  is  in 
just  this  class  of  case  that  the  use  of  the  pessary  helps  so  much  to 
hasten  the  cure.     When  the  knee-chest  position  or  pessary  treat- 


RETRODISPLACEMENTS  OF  THE   UTERUS  li^i[ 

merit  is  not  persisted  in  long  enough,  the  benefit  will  be  only  tem- 
porary, and  the  displacement  of  the  uterus  eventually  becomes 
permanent. 

We  may  then  consider  that  abnormal  mobility  is  an  inter- 
mediate condition  between  the  normal  and  the  pathological,  and 
should  always  be  considered  as  a  border-line  condition,  more  or 
less  pathological  in  itself.  Thus  it  may  be  said  that  overrelaxation 
of  the  uterine  supports,  with  excessive  mobility  of  the  organ  itself, 
is  a  condition  of  considerable  importance  and  one  that  is  more 
favorable  to  treatment  in  its  early  stages  than  after  it  has  existed 
for  some  length  of  time.  In  the  early  stages  many  a  permanent 
cure  may  be  accomplished  by  a  six  months'  pessary  treatment  that 
at  a  later  period  would  require  surgical  treatment  for  its  correc- 
tion. When  displacement  of  the  uterus  once  begins,  the  condition 
is  usually  progressive,  going  on  steadily  from  bad  to  worse,  so 
that  with  the  general  tissue  relaxation  of  advancing  years,  many 
a  first  degree  prolapse  later  develops  into  a  complete  procidentia. 

For  the  purpose  of  classification  the  retrodisplacements  may 
be  considered  from  several  different  points  of  view,  but  all  may 
be  included  in  two  divisions:  congenital  and  acquired.  The  con- 
genital originate  either  during  fetal  life,  or  in  early  childhood,  the 
result  of  imperfect  development,  and  are  essentially  different  from 
the  acquired  type.  These  latter  occur  later  in  life  and  are  either 
traumatic  in  origin  or  result  from  factors  arising  from  childbear- 
ing.  The  congenital  type  is  of  particular  importance  and  calls  for 
early  replacement,  because  the  influence  exerted  by  the  continued 
displacement  leads  to  permanent  changes  in  the  immature  organ. 
In  the  acquired  type  arising  later  in  life,  at  a  time  when  the  uterus 
has  achieved  its  full  development,  permanent  pathological  changes 
are  not  so  liable  to  result. 

Retrodisplacement  of  the  uterus  becomes  an  active  factor  in 
the  causation  of  sterility  in  one  of  two  ways;  either  the  patho- 
logical changes  in  the  uterus  resultant  upon  its  abnormal  position 
prevent  conception  or  result  in  an  interference  with  pregnancy 
when  conception  has  occurred.  Many  displacements  are  at  some 
time  or  other  accompanied  by  inflammatory  processes  in  the 
uterus  itself  and  such  chronic  inflammations  must  be  considered 
partly  as  a  cause  and  partly  as  a  consequence  of  the  displacement. 
The  pathological  changes  which  occur  in  the  uterus  itself  as  a 
result  of  the  displacement  vary  according  to  the  length  of  time 


114  STERILITY  AND   CONCEPTION 

the  displacement  has  existed.  The  first  change  that  takes  place 
in  every  displacement  is  a  venous  stasis,  or  congestion.  As  time 
goes  on  this  congestion  becomes  chronic,  leading  to  permanent 
changes  in  the  uterus  itself.  The  most  prominent  of  these  is  an 
increase  in  connective  tissue  in  the  uterine  w^alls,  and  a  thickening 
or  overgrow^th  of  the  endometrium,  know^n  as  hyperplasia  or 
hypertrophy.  In  the  retrodisplacements  associated  with  subinvo- 
lution, such  as  are  encountered  in  parous  women,  there  is  a  gen- 
eral profuse  overgrowth  of  connective  tissue,  replacing  to  a 
certain  extent  the  muscular  elements  of  the  uterus.  Adhesions  in 
the  pelvis  are  responsible  at  times  not  only  for  maintaining  the 
retrodisplacement  but  actually  interfere  with  its  replacement. 
Inflammatory  disease  of  the  adnexa  with  extensive  adhesions 
often  hold  the  uterus  in  a  position  of  retroversion  long  after  the 
acute  process  has  subsided.  While  it  is  quite  true  that  the  retro- 
displaced  uterus  may  become  pregnant,  and  that  the  pregnancy 
may  even  correct  the  displacement  spontaneously  as  the  uterus 
enlarges,  the  pregnancy  then  going  on  to  term,  we  know  by 
experience  that  this  is  the  exception  rather  than  the  rule.  Ordi- 
narily the  retrodisplaced  pregnant  uterus  begins  to  show  evidence 
of  distress  as  the  end  of  the  third  month  approaches,  and  if  it  is 
not  promptly  replaced,  the  pregnancy  usually  terminates  in  an 
abortion.  In  view  of  the  fact  that  the  retrodisplaced  uterus  is 
associated  with  a  high  degree  of  sterility  and  a  low  degree  of  fer- 
tility, the  displacement  should  always  be  corrected,  preferably 
before  pregnancy  has  occurred.  Many  cases  of  habitual  abortion 
in  the  early  months  are  due  to  a  retrodisplacement,  and  many  of 
these  are  in  women  who  have  never  borne  children,  in  whom  the 
displacement  is  of  the  congenital  type.  The  following  case  is  an 
example  of  this  class: 

Mrs.  M.  T.,  when  first  seen,  was  twenty-nine  years  of  age  and  had  been  married 
four  years  without  ever  having  given  birth  to  a  viable  child.  Menstruation  had 
been  regular  since  its  onset  at  the  age  of  fourteen  years,  of  five  days'  duration, 
moderate  in  amount  and  painless.  She  had  suffered  from  three  abortions  for  no 
known  cause.  These  had  all  occurred  at  a  period  between  the  second  and  third 
month. 

Examination  showed  a  rather  small  and  extremely  retroflexed  uterus,  with  a 
large,  tender,  prolapsed  right  ovary.  A  diagnosis  of  relative  sterility  was  made, 
and  under  a  general  anesthetic  the  uterus  was  replaced,  carrying  the  ovary  with  it, 
and  a  retroflexion  pessary  inserted.  After  this  treatment  she  menstruated  the  first 
and  second  months  following;  conception  then  occurred  during  the  third  month 
and  she  was  delivered  at  term  of  a  living  child.    Two  years  later  she  bore  a  second 


RETRODISPLACEMENTS  OF  THE   UTERUS  115 

living  child.     The  retroflexion  recurred  after  each  delivery,  but  yielded  to  pessary 
treatment  in  the  intervals. 

Habitual  Abortion  Due  to  Congenital  Retrodisplacement  of 
Uterus. — The  majority  of  cases  of  habitual  abortion  associated 
with  congenital  retrodisplacement  of  the  uterus  will  be  found  to 
have  a  short  anterior  vaginal  wall  that,  while  the  fundus  can 
readily  be  brought  forward,  will  not  allow  the  cervix  to  swing 
back  into  the  hollow  of  the  sacrum  where  it  belongs,  but  keeps  it 
forward  in  the  axis  of  the  vagina.  This  prevents  the  pessary  from 
holding  the  uterus  in  normal  position,  even  though  it  is  possible  to 
accomplish  the  replacement.  In  such  cases  the  anterior  vaginal 
wall  must  be  lengthened  in  order  to  permit  replacement  of  the 
cervix  as  well  as  of  the  fundus.  This  is  accomplished  by  a  trans- 
verse incision  made  at  the  junction  of  the  vagina  with  the  cervix. 
Through  this  incision  it  it  well  to  free  the  uterovesical  ligament 
from  its  attachment  to  the  cervix  and  reattach  it  at  a  point  high 
enough  up,  to  allow  the  cervix  to  swing  back  into  the  hollow  of 
the  sacrum,  perpendicular  to  the  vaginal  axis.  In  most  ot  these 
cases  this  should  be  done  as  routine  when  lengthening  out  the 
anterior  vaginal  wall.  The  transverse  incision  in  the  anterior 
vaginal  wall  is  then  sutured  in  a  longitudinal  direction,  by  which 
procedure  the  lengthening  out  is  accomplished.  As  an  instance  of 
this  type  the  following  case  history  is  given : 

Mrs.  H.  H.,  age  twenty-two  years,  had  been  married  two  years  without  ever 
having  given  birth  to  a  viable  child.  Menstruation,  which  began  at  twelve  years 
of  age,  was  always  regular,  lasting  three  days,  moderate  in  amount  and  accom- 
panied by  only  slight  pain.  She  had  conceived  twice,  both  pregnancies  ending  in 
abortions  before  the  third  month,  without  assignable  cause. 

Examination  showed  a  retroflexed  uterus,  with  a  short  anterior  vaginal  wall, 
and  replacement  could  not  be  effected.  No  other  pathological  lesion  was  made  out. 
Through  a  vaginal  incision  the  uterovesical  ligament  was  freed  and  reattached  at  a 
point  sufficiently  high  up  on  the  uterus  to  allow  the  cervix  to  go  back  into  the 
hollow  of  the  sacrum.  The  anterior  vaginal  wall  was  then  lengthened.  The  uterus 
was  replaced  and  a  suitable  pessary  introduced.  The  next  conception  occurred 
within  two  months,  and  she  carried  this  pregnancy  through  to  a  successful  issue, 
being  delivered  at  term  of  a  living  child. 

The  displacement  recurred  postpartum,  and  for  this  she  was  treated  with  a 
pessary  for  four  months.  At  the  end  of  this  time  it  was  removed  and  the  uterus 
remained  in  place.  With  the  next  pregnancy,  it  again  retroflexed,  but,  being 
promptly  replaced,  the  pregnancy  went  on  to  term  without  any  interruption,  and 
she  was  delivered  of  a  second  living  child  at  term.  Once  again  there  jvas  a  post- 
partum recurrence  of  the  displacement,  which  yielded  as  in  the  first  instance  to  a 
few  months'  use  of  the  pessary. 


ii6  STERILITY  AND  CONCEPTION 

The  above  case  is  an  excellent  example  of  the  usual  inability 
of  the  congenital,  retroflexed  uterus  to  carry  a  pregnancy  beyond 
the  first  few  months  and  illustrates  how  readily  the  condition  may 
be  corrected  by  the  use  of  the  pessary.  It  is  not  often  that  any 
operative  procedure  other  than  lengthening  of  the  anterior  vaginal 
wall  and  reattachment  of  the  uterovesical  ligament  will  be  found 
necessary,  and  even  this  latter  may  be  sometimes  omitted.  To 
subject  such  a  case  to  a  major  surgical  risk  for  the  correction  of 
the  displacement  is  rarely  warranted. 

Postpartum  Retrodisplacement. — Postpartum  retroflexion  of 
the  uterus  may  also  prevent  another  conception  or  cause  habitual 
abortion  in  the  early  months.  In  these  cases  replacement  is  usually 
the  easier  of  accomplishment,  provided  adhesions  are  not  present, 
and  the  results  are  equally  as  good.  The  anterior  vaginal  wall 
lengthening  and  ligament  operation  do  not  need  to  be  performed. 

The  adherent  retroflexion  cases  require  an  operative  separa- 
tion of  the  adhesions  before  replacement  can  be  accomplished  and 
in  addition  shortening  of  the  ligaments  to  retain  the  uterus  in 
place.  The  following  cases  illustrate  somewhat  different  phases 
of  this  type : 

Mrs.  D.  O.  was  forty  years  old  and  had  been  married  three  years  without  ever 
having  been  pregnant.  Menstruation  began  at. fourteen  years  of  age,  was  always 
regular,  lasting  seven  days,  but  accompanied  by  severe  pain. 

Examination  showed  a  small,  retroverted  and  adherent  uterus  with  enlarged, 
prolapsed,  and  tender  appendages  on  the  left  side.  At  operation,  an  abdominal 
incision  was  made  and  the  uterus  found  adherent  in  extreme  retroversion.  Both 
ovaries  were  prolapsed  and  likewise  adherent.  The  tubes  were  free,  but  short  and 
situated  high  up  on  the  broad  ligaments.  All  adhesions  were  separated  and  the  left 
ovary,  which  showed  marked  cystic  enlargement,  was  resected.  The  round  and 
utero-sacral  ligaments  were  shortened  to  correct  the  retrodisplacement.  Fourteen 
months  after  the  operation  she  was  delivered  at  term  of  a  living  child. 

Considering  the  advanced  age  of  the  patient,  the  long  period  of  sterility  and 
its  prompt  relief  through  operation,  this  case  is  a  remarkable  one  and  a  most 
encouraging  example  of  the  promptness  with  which  Nature  will  act  if  only  given 
proper  assistance. 

Mrs.  R.  H.,  thirty-one  years  of  age,  was  married  two  years,  during  which  time 
she  had  not  conceived.  Menstruation  began  at  twelve  years  of  age,  regular,  five 
days*  duration,  moderate  in  amount  and  accompanied  by  severe  pain. 

On  examination  the  uterus  was  found  to  lie  in  retroflexion  and  the  right 
ovary  was  enlarged,  tender,  prolapsed,  and  adherent.  The  husband's  semen  was 
normal.  A  diagnosis  of  conditional  sterility  was  made.  At  operation  the  right 
ovary  showed  an  enlargement  of  venous  stasis  resulting  from  its  displacement.  It 
was  freed  from  adhesions  and  replaced  with  the  uterus.  The  round  and  retro- 
sacral  ligaments  were  shortened  and  the  appendix  removed.     Eight  months  later 


RETRODISPLACEMENTS  OF  THE  UTERUS  117 

she  conceived,  but  aborted  at  two  months  after  a  prolonged  and  painful  session 
with  her  dentist.  Within  six  months  she  again  conceived,  but,  being  more  careful 
this  time,  carried  to  term  and  was  delivered  of  a  living  child.  There  has  been  no 
recurrence  of  the  retroflexion. 

Mrs.  J.  McK.,  thirty-seven  years  of  age,  and  eight  years  married.  Has  never 
been  pregnant.  Menstruation  began  at  thirteen  years  of  age,  was  always  regular, 
lasting  three  days,  moderate  in  amount  and  painless.  The  husband's  semen  was 
normal. 

Examination  showed  an  adherent  uterus  with  prolapsed,  adherent  left  adnexa. 
Diagnosis  was  conditional  sterility.  At  operation  both  ovaries  were  found  adherent 
to  the  posterior  face  of  the  broad  ligament  and  the  uterus  slightly  adherent  to  the 
rectum.  The  tubes  were  normal.  The  adhesions  were  separated,  the  uterus 
replaced  and  its  round  ligaments  shortened.  Convalescence  was  uneventful, 
though  protracted,  and  as  she  was  in  wretched  general  health  and  had  been  for 
some  time,  coitus  was  prohibited  for  one  year.  At  the  end  of  this  time  she  had 
regained  excellent  health  and  the  ban  on  intercourse  was  removed.  Conception 
took  place  shortly  thereafter  and  she  went  through  a  normal  pregnancy  to  term, 
only  to  lose  her  life  from  accidental,  concealed  hemorrhage  due  to  a  premature 
separation  of  the  placenta. 

Pregnancy  after  Operative  Correction  of  Retrodisplacements. 

— When  pregnancy  results  shortly  after  the  operative  correction  of  a 
retrodisplacement  the  patient  should  always  wear  a  pessary  for  the 
first  four  months  of  her  pregnancy.  This  is  advisable  not  only  to 
relieve  the  freshly  shortened  ligaments  from  the  strain  of  holding 
in  place  the  increasingly  heavy  uterus,,  but  as  a  precautionary 
measure  against  a  recurrence  of  the  displacement  with  the  danger 
of  abortion.  After  the  fourth  month,  when  the  uterus  has  risen 
out  of  the  pelvis  sufficiently  to  attain  the  support  of  the  sacral 
promontory,  retrodisplacement  becomes  impossible  and  the  pes- 
sary can  then  be  removed  with  safety. 

Mrs.  E.  H.,  twenty-two  years  of  age,  was  operated  ripon  for  an  extreme, 
unreducible  retroflexion  of  the  uterus,  accompanied  by  prolapse  of  both  ovaries. 
Following  the  operation,  as  the  patient  was  to  be  in  a  distant  city  for  six  months, 
a  retroflexion  pessary  was  introduced  as  a  precautionary  measure.  Coitus  was 
not  allowed  for  three  months  after  operation.  During  the  fourth  month  it  was 
resumed  and  conception  occurred.  The  pessary  was  removed  at  the  end  of  the 
fourth  month  of  pregnancy  and  she  was  delivered  at  term  of  a  living  child.  Sub- 
sequent examination  showed  no  return  of  the  displacement.  "^ 

Treatment  of  Retrodisplacements. — Before  deciding  on  the 
line  of  treatment  to  be  carried  out  in  any  individual  case  of  retro- 
displacement, it  is  necessary  to  distinguish  the  special  type  to 
which  the   displacement  belongs.      In  the   congenital   form,   the 


ii8  STERILITY  AND  CONCEPTION 

earlier  the  displacement  is  corrected  the  greater  the  chance  of 
effecting  a  cure.  If  the  uterus  in  such  cases  were  put  in  normal 
position  at  the  time  of  puberty,  it  would  probably  function  in  as 
normal  a  manner  as  though  it  had  never  been  displaced.  My  best 
results  with  these  cases  have  been  obtained  when  I  have  been  able 
to  correct  the  displacement  very  soon  after  the  onset  of  menstrua- 
tion. Occasionally  menstruation  begins  with  such  very  marked 
symptoms  and  such  extreme  suffering  on  the  part  of  the  patient 
that  the  gynecologist  is  consulted  at  once.  If  the  parents  of  the 
girl  are  intelligent  enough  to  understand  the  condition,  they 
usually  accept  the  situation,  and  request  the  operative  replace- 
ment of  the  uterus;  but  more  often  they  take  the  stand  that 
because  the  girl  is  but  a  child,  and  not  a  woman,  it  is  impossible 
tor  her  to  have  any  "female  complaint,"  as  they  are  pleased  to  put 
it.  If  one  has  been  careful  to  previously  inquire  into  the  menstrual 
history  and  then  to  investigate  the  pelvic  condition  when  operat- 
ing on  interval  cases  of  appendicitis  in  young  girls,  the  oppor- 
tunity will  often  present  itself  to  correct  a  congenital  displacement 
at  the  time  the  appendix  is  removed.  In  congenital  cases,  the 
pessary  is  not  to  be  considered  alone  as  a  method  of  treatment,  as 
it  does  not  cure  such  cases  and  is  associated  with  a  more  or  less 
frequent  handling  of  the  genitals  that  should  always  be  avoided 
in  young  girls. 

We  are  thus  limited  in  these  cases  almost  exclusively  to 
surgical  measures.  The  anterior  vaginal  wall  should  be  length- 
ened and  the  utero-vesical  ligament  attached  at  a  somewhat 
higher  point  on  the  cervix.  This  procedure  allows  the  cervix  to 
swing  freely  back  perpendicular  to  the  axis  of  the  vagina  as  the 
fundus  is  brought  forward,  and  in  many  cases  no  further  operative 
procedures  are  required,  provided  the  fundus  can  be  kept  forward 
long  enough  to  allow  the  round  ligaments  to  shorten  sufficiently 
to  hold  it  in  place  permanently.  After  the  plastic  work  on  the 
anterior  vaginal  wall  and  utero-vesical  ligament  has  been  carried 
out,  a  retroversion  pessary  is  introduced  and  allowed  to  remain 
for  from  four  to  six  months.  It  is  usually  not  necessary  to  remove 
it  more  than  once  or  twice  during  this  time,  when  a  light  anes- 
thetic may  be  given,  if  desired. 

If  this  treatment  does  not  suffice,  it  will  be  necessary  to 
shorten  the  round  and  utero-sacral  ligaments  in  order  to  effect  a 
permanent  cure.    In  traumatic  retrodisplacements,  if  seen  at  the 


RETRODISPLACEMENTS  OF  THE  UTERUS  119 

time  of  the  accident  or  shortly  afterwards,  and  taken  promptly  in 
hand,  replacement  of  the  uterus  and  the  use  of  a  pessary  will 
usually  effect  a  cure.  When  the  displacement  has  existed  for  a 
year  or  more,  the  use  of  the  pessary  will  not,  as  a  rule,  prove 
curative,  and  resort  will  have  to  be  had  to  surgery. 

Postpartum  retrodisplacements  offer  the  greatest  hope  of  a 
cure  by  the  pessary,  but  prophylaxis  is  quite  important  in  this 
type.  The  prolonged  dorsal  position  assumed  by  the  average 
woman  after  childbirth  is  undoubtedly  responsible  for  many  retro- 
displacements.  After  the  first  few  days,  following  delivery,  it  is 
wiser  for  the  woman  to  keep  on  her  side,  and  a  certain  part  of  the 
time  on  her  face.  Many  women  are  in  the  habit  of  lying  on  their 
face  in  bed,  so  that  this  form  of  treatment  is  to  them  no  great 
hardship.  In  this  position  gravity  will  keep  the  fundus  forward 
by  relieving  all  strain  on  the  round  ligaments,  enabling  them  to 
involute  more  quickly  and  more  thoroughly.  If  the  parturiate  woman 
never  lay  on  her  back,  the  number  of  postpartum  retrodisplace- 
ments would  be  very  few.  After  delivery,  say  between  the  third 
and  fourth  week,  a  pelvic  examination  should  be  made  and  the 
position  of  the  uterus  determined.  If  it  is  retrodisplaced,  the  dis- 
placement should  be  corrected  and  a  pessary  introduced.  If  the 
patient  has  suffered  from  a  displacement  after  a  previous  delivery, 
it  is  best  to  introduce  the  pessary  as  a  prophylactic  measure  even 
though  no  displacement  be  made  out.  When  the  uterus  is  found 
in  a  normal  position,  repeated  examinations  should  nevertheless 
be  made  throughout  the  six  months  following  delivery,  and  no 
chance  taken  of  overlooking  a  late  displacement.  It  has  been  my 
experience  that  in  cases  of  postpartum  displacement  the  pessary 
treatment  is  invariably  successful  when  instituted  early.  My 
obstetrical  records  show  postpartum  retrodisplacements  in  37.2 
per  cent.  In  the  cases  where  the  displacement  had  existed  before 
delivery,  it  always  recurred  postpartum.  In  every  case  of  post- 
partum retrodisplacement  there  was  a  recurrence  with  succeeding 
deliveries,  and  in  many  of  these  cases  there  was  a  recurrence  in 
the  early  months  of  succeeding  pregnancies.  Just  how  often  this 
would  have  occurred  without  treatment  I  cannot  say,  because  in 
these  patients  I  always  introduce  a  pessary  as  a  prophylactic 
measure  whenever  the  diagnosis  of  pregnancy  is  made  before  the 
fourth  month.  Thus  in  a  general  way  I  may  say  that  when  a  dis- 
placement occurs  postpartum,  it  will  always  recur  with  succeeding 


I20  STERILITY  AND  CONCEPT  ON 

confinements  and  often  in  the  early  months  of  pregnancy  as  well. 
With  the  proper  use  of  the  pessary  for  from  four  to  six  months 
postpartum,  a  subsequent  operation  for  the  displacement  will  be 
avoided.  Occasionally  cases  will  be  encountered  unsuited  to  the 
use  of  the  pessary  because  of  a  laceration  and  wide  separation  of 
the  levator  muscles.  In  these,  after  a  perineal  repair,  the  pessary 
can  often  be  used,  with  success. 

The  pessary  may  not  always  effect  a  permanent  cure,  but  if 
properly  fitted  will  keep  the  uterus  in  place  long  enough  to  cure 
the  sterility.  Some  cases  cannot,  and  many  should  not,  be  sub- 
jected to  a  major  operative  procedure  for  the  correction  of  a  dis- 
placement where  the  uterus  can  be  kept  in  position  by  a  pessary, 
even  though  the  pessary  may  have  to  be  worn  over  a  considerable 
period  of  years. 

Little  is  to  be  gained  by  the  line  of  treatment  often  advised  of 
gradually  raising  the  uterus  into  position  by  the  use  of  tampons. 
Suitable  medicated  tampons  are  occasionally  of  value  as  a  prelim- 
inary treatment  to  replacement,  but  only  with  the  idea  of  relieving 
the  congestion  and  pelvic  tenderness  that  make  replacement  dif- 
ficult, or  impossible,  without  the  administration  of  a  general 
anesthetic. 

The  retroflexed  gravid  uterus  should  always  be  replaced  as 
soon  as  the  diagnosis  is  made.  If  this  is  done,  and  a  pessary  worn 
for  from  three  to  four  months,  many  an  abortion  or  serious  opera- 
tion will  be  prevented,  and  the  danger  of  incarceration  avoided. 
It  is  true  that  once  in  a  while  the  retrodisplacement  is  corrected 
spontaneously  in  the  course  of  the  pregnancy,  but  this  is  the 
exception,  not  the  rule,  and  early  manual  replacement  is  always 
to  be  advised. 


LITERATURE 

Baldy,  J.  B.    S.  G.  &  O.     1909. 

Child,  Jr.,  C  G.    Diseases  of  Women.     1909. 

CoE,  H.  C    N.  Y.  M.  J.    1901. 

Dickinson,  S.  C.    Am.  Journ.  Obstet.    1911. 

Edebohls.    Am.  Gyn.  and  Obstet.    1897. 

GoFFE,  J.  R.    Am.  Jour.  Obstet.    Vol.  XLIX.    1904. 

HoDDiN,  D.    Am.  Journ.  Obstet.    19 14. 


RETRODISPLACEMENTS  OF  THE   UTERUS  121 

Noble,  C.  P.  The  Treatment  of  Retrodisplacements  of  the 
Uterus.     1905. 

O'SuLLivAN,  M.  U,  The  Prodivity  of  Civilized  Woman  to 
Uterine  Displacements.     1894. 

Pfannenstiel.     Monatsschr.  f.  Geburtsch.  u.  Gyn.     1903. 

ScHULTZ,  B.  S.  Die  Pathologic  und  Therapie  der  Lagerverander- 
ungen  der  Gebarmutter.     1881. 

Smith,  P.    Brit.  Med.  Joum.    1872. 


CHAPTER  XVI 

OVARIAN  STERILITY 

Gross  and  histological  description  of  nonovulating  ovary — Case  reports — Ovarian 
disease — Operative  treatment  of  ovarian  sterility — Ovarian  decapsulation. 

As  conception  can  only  result  from  the  proper  conjugation  of 
a  spermatozoon  and  an  ovum,  deficient  ovulation  becomes  an 
absolute  bar  to  fecundation.  This  form  of  sterility  has  long  been 
the  least  understood  of  any,  and  much  of  great  value  regarding 
it  has  recently  been  developed  by  the  work  of  Edward  Reynolds. 

Gross  and  Histological  Description  of  Nonovulating  Ovary. — 
His  description  of  the  nonovulating  ovary,  from  both  the  gross 
and  histological  point  of  view,  is  so  carefully  and  brilliantly 
worked  out  that  I  cannot  possibly  do  better  than  to  quote  him  at 
length.     He  says: 

"At  the  start  emphasis  must  be  laid  on  the  basic  fact  that  the 
human  female  is  a  uniparous  animal,  and  her  ovaries,  like  those  of 
other  animals  which  normally  bear  but  one  at  birth,  normally 
contain,  at  one  time,  but  one  fully  mature  follicle,  and  in  conse- 
quence of  this  single  occurrence  of  the  mature  follicle,  but  one 
recent  and  active  corpus.  The  multifollicular  and  multicorporal 
condition  which  is  characteristic  of  pluriparous  animals  is  not  nor- 
mal in  the  human  female.  The  ovaries  of  a  fertile  woman  are, 
then,  characteristically  organs  of  uniform  outline  which  show 
not  more  than  one  thin-walled  and  projecting  follicle  or  corpus 
(except  during  pregnancy  and  lactation).  They  have  throughout 
a  characteristic  soft  and  elastic  feel  when  taken  between  the 
fingers,  except  when  a  single  mature  follicle  or  active  corpus 
distends  one  portion  of  an  ovary  and  yields  its  characteristic  tac- 
tile sensation  at  that  point.  In  contrast,  the  ovaries  of  sterile 
women  usually  show  on  gross  examination  the  presence  of  numer- 
ous thin-walled  projecting  follicles,  or  of  numerous  small  imper- 
fect-looking corpora,  or  both.  They  are  of  lobulated  outline,  and 
on  tactile  examination  between  the  fingers  are  tense  and  resistant 


OVARIAN  STERILITY  123 

in  feel  over  the  whole,  or,  at  all  events,  the  greater  part  of  the 
organ," 

In  the  histological  explanation  of  these  clinical  facts,  he  recog- 
nizes three  types  of  mature  follicles  and  two  types  of  corpora. 
In  the  first  type  of  mature  follicle  the  membrana  granulosa  forms 
a  continuous  lining  in  the  whole  follicle.  The  follicle  enlarges  and 
undergoes  progressive  protrusion  from  the  surface  of  the  ovary 
until  it  ruptures,  discharging  part  of  the  discus  proligerus  when 
the  formation  of  the  corpus  begins. 

The  second  type  has  a  different  structural  organization.  There 
are  two  layers  of  theca,  and  the  membrana  granulosa  is  not  con- 
tinuous, but  is  found  to  be  in  varying  stages  of  disintegration. 
This  second  type  is  apparently  functionally  imperfect  and  its 
multiple  presence  at  the  surface  of  the  ovary  is  highly  character- 
istic of  the  ovaries  in  sterile  women. 

The  third  type  of  follicle  he  dismisses  as  unimportant  with  the 
statement  that  "they  are  usually  hemorrhagic,  differ  essentially 
in  the  histology  of  the  internal  and  external  theca,  and  are  prob- 
ably incipient  cystomas." 

In  the  case  of  the  corpora  resulting  from  these  follicles,  it  is 
uncertain  whether  they  are  induced  by  rupture  or  the  complete 
disintegration  gf  the  membrana  granulosa.  These  corpora  do 
not  always  contain  typical  lutein  cells,  and  by  some  are,  there- 
fore, described  as  pseudo-corpora.  The  corpora  from  the  second 
type  of  follicle  are  smaller  than  those  from  the  first,  and  their 
development  less  mature.  In  classifying  the  ovaries,  examined 
with  the  clinical  histories  of  the  women,  it  appeared  that  the 
second-type  follicles  and  corpora  all  belonged  to  sterile  women; 
while  those  with  the  first-type,  or  normal  follicles  and  corpora, 
belonged  to  fertile  women. 

Cases  where  the  sterility  is  due  to  some  ovarian  condition 
alone  are  not  as  a  rule  very  often  met  with.  Ruling  out  those 
cases  where  the  ovaries  are  the  seat  of  malignant  disease  and  the 
sterility,  of  course,  incurable,  we  find  two  conditions  most  fre- 
quently encountered.  In  the  one  there  is  a  complete  envelopment 
of  the  ovary  by  adhesions,  thus  shutting  of¥  all  chance  of  the 
ovum's  reaching  the  tube,  and  in  the  second  the  ovaries  are  found 
cystically  enlarged  with  greatly  thickened  cortex,  showing  an 
entire  absence  of  any  scars  that  would  denote  a  previous  graafian 
follicle  rupture. 


124  STERILITY  AND  CONCEPTION 

In  the  first-mentioned  class,  it  is  very  seldom  that  we  find  the 
ovaries  to  be  completely  shut  off  in  adhesions,  without  there  is  an 
accompanying  involvement  and  closure  of  the  tube;  but  in  the 
second  class  the  disease  process  affects  the  ovaries  directly,  sel- 
dom, if  ever,  involving  the  tubes,  which  will  be  found  nearly 
always  patent.  Only  once  at  operation  have  I  encountered  ovaries 
normal  in  size  and  noncystic  that  showed  no  microscopic  evidence 
of  any  previous  graafian  follicle  rupture.  This  patient  had  prob- 
ably never  ovulated.  I  believe  this  condition  to  be  an  extremely 
rare  one,  and  I  deeply  regret  that  there  was  no  justification  for 
the  removal  of  one  of  the  ovaries  for  microscopical  study.  It  is  in 
all  probability  then,  very  seldom  that  there  is  any  obstruction  to 
normal  ovulation.  The  mature  follicle  reaches  the  cortex  of  the 
ovary  and  without  any  difficulty  is  able  to  rupture  and  discharge 
its  ovum ;  only  where  the  cortex  has  become  thickened  does 
rupture  become  more  difficult,  and  it  is  not  until  a  final  stage  in 
this  process  is  reached  that  the  thickening  prevents  the  final  suc- 
cessful liberation  of  the  ovum.  In  such  the  follicles  are  unable  to 
empty  and,  not  being  absorbed,  remain  as  retention  cysts.  These 
retention  cysts  multiply  as  time  goes  on  until  they  eventually 
greatly  increase  the  size  of  the  ovary.  This  is  often  accompanied 
by  a  chronic  inflammatory  process  that  further  enlarges  the  ovary. 
A  most  instructive  example  of  this  class  of  case  was  the  following: 

Mrs.  C.  P.,  operation  on  May  14,  1910,  in  the  Polyclinic  Hospital,  was  twenty- 
two  years  old  and  had  been  married  three  years.  From  the  onset  of  her  menstrua- 
tion she  had  always  suffered  from  dysmenorrhea,  backaches,  and  continually 
increasing  pelvic  pain.  She  had  never  been  pregnant.  Examination  showed  a 
uterus  of  extreme  anteflexion,  but  normal  in  size,  and  with  no  demonstrable  lesion 
of  the  adnexa.  At  operation  the  tubes  were  found  to  be  normal  and  could  be 
probed  free  into  the  uterine  cavity.  Both  ovaries  were  enlarged,  cystic,  and  with 
greatly  thickened  cortex.  A  careful  inspection  failed  to  disclose  the  presence  of 
any  scars  that  would  denote  previous  graafian  follicle  rupture,  and  it  was,  there- 
fore, concluded  that  the  case  was  one  of  sterility  due  to  defective  ovulation. 

The  operative  treatment  carried  out  was  resection  of  both  ovaries,  and  from 
the  right  ovary  the  entire  thickened  capsule  was  removed.  Convalescence  was 
uneventful,  and  during  the  succeeding  j'ear  she  gave  birth  at  term  to  a  living  child. 
Three  years  later  another  was  born.  When  last  heard  from  both  children  were 
living,  and  she  was  pregnant  for  the  third  time. 

Another  instance  of  this  same  ovarian  condition  was  found  in 
the  following  case : 

Mrs.  J.  G.,  twenty-five  years  of  age,  gave  a  history  of  two  years'  sterile  mar- 
ried  life.      Her   symptoms   in    addition    to   the   chief   complaint  of    sterility   were 


OVARIAN   STERILITY  125 

occasional  pelvic  pain,  backaches,  and  dysmenorrhea.  In  addition  to  these  she 
suffered  from  frequent  distressing  attacks  of  mental  depression  because  of  her 
childless  home. 

Examination  showed  a  small,  mobile,  retroverted  uterus  with  no  demonstrable 
involvement  of  the  appendages.  The  retrodisplacement  was  of  the  congenital  type, 
associated  with  a  short  anterior  vaginal  wall.  At  operation  on  September  17,  1917, 
in  the  Polyclinic  Hospital,  the  anterior  vaginal  wall  was  lengthened,  and  at  her 
request,  the  abdomen  opened  so  that  no  possible  etiological  factor  in  her  sterility 
should  be  overlooked.  Both  tubes  were  normal  and  were  probed  free  to  the  uterine 
cavity.  The  ovaries  showed  only  slight  cystic  enlargement,  but  with  great  thicken- 
ing of  the  cortex,  and  no  graafian  follicle  scars  could  be  seen.  The  entire  surface 
of  both  ovaries  was  smooth,  regular,  and  glass-like  in  appearance.  The  ovaries 
were  resected  and  a  cortical  stripping  of  the  right  performed.  The  uterus  was 
then  replaced  and  the  round  ligaments  shortened.  Convalescence  was  uneventful. 
She  became  pregnant  three  months  later  and  was  delivered  of  a  living  child  at 
term. 

Ovarian  Disease. — Unilateral  ovarian  disease,  of  course,  does 
not  necessarily  cause  sterility,  and  many  patients  with  even  large 
ovarian  cysts  are  repeatedly  delivered  without  complications. 

Operative  Treatment  of  Ovarian  Sterility. — For  the  treatment 
of  ovarian  sterility  we  are  almost  wholly  dependent  on  surgical 
measures.  All  adhesions,  whether  only  limiting  the  normal 
mobility  of  the  ovary  or  so  enveloping  it  as  to  prevent  the  ovum 
from  getting  to  the  tube,  must  be  freed.  Marked  benefit  results 
from  resection  where  the  ovary  is  cystically  enlarged,  while  simple 
congestive  enlargement  caused  by  prolapse  will  usually  subside 
when  the  ovary  is  replaced. 

Ovarian  Decapsulation. — In  the  rarer  cases  where  the  cortex 
of  the  ovary  is  so  thickened  as  to  prevent  the  rupture  of  the 
graafian  follicles,  decapsulation  of  one  or  both  ovaries  should  be 
carried  out.  Ovarian  transplantation  has  been  successfully  per- 
formed, but  I  feel  is  as  yet  too  much  in  the  field  of  experimenta- 
tion to  be  considered  here. 


CHAPTER   XVII 

FIBROID  STERILITY 

Fibroids — Relation    of    fibroids    to    sterility    and    fertility — Case    history — Uterine 
myomata — Case  histories — Myomectomy. 

In  taking  up  the  consideration  of  this  phase  of  sterility,  much 
difficulty  is  at  once  encountered  if  we  endeavor  to  apportion  to 
fibroids  their  relative  place  as  a  causative  factor  in  sterility.  I 
shall,  therefore,  make  no  attempt  to  enter  a  field  where  so  many 
have  failed.  That  many  women  with  fibroids  bear  children  and 
that  some  even  show  a  relatively  high  degree  of  fertility  cannot 
be  denied,  but  the  consensus  of  opinion  among  gynecologists 
to-day  is  that  the  presence  of  these  tumors  in  the  uterus  is  usually 
associated  with  a  high  rate  of  sterility  and  a  low  rate  of  fertility. 
I  have  used  the  expression  "in  the  uterus"  advisedly,  because  the 
pedunculated  tumors  which  lie  outside  of  the  uterus  act  only 
indirectly  on  the  child-bearing  function  of  the  woman. 

Fibroids. — Fibroids  are  a  very  common  growth  of  the  uterus 
and  are  encountered  more  frequently  in  some  races  than  in  others. 
Clinical  records  probably  very  greatly  underestimate  their  fre- 
quency, for  unless  they  reach  a  sufficient  size  to  attract  notice 
or  produce  well-recognized  clinical  symptoms,  they  are  often 
overlooked. 

Numerous  observers  have  reported  on  the  presence  of  fibroids 
in  cases  of  sterility  and  lowered  fertility,  and  their  records  show 
a  frequency  of  between  twenty  and  thirty  per  cent  in  all  cases, 
and  twelve  to  fifteen  per  cent  in  women  who  had  borne  one  child 
only.  The  question  of  age  has  entered  prominently  into  all  dis- 
cussions relating  to  fibroids  and  sterility,  but  it  has  always 
seemed  to  me  without  sufficient  reason.  From  thirty-five  to  forty 
years  is  the  age  at  which  these  tumors  most  frequently  occur,  so 
that  before  thirty  they  are  generally  considered  as  having  little 
bearing  on  sterility,  but  we  know  that  fibroids  grow  slowly  for 

126 


FIBROID  STERILITY 


127 


years,  causing  only  slight  or  no  symptoms  at  all,  and  that  when 
finally  diagnosed  they  may  have  been  present  for  quite  a  number 
of  years.  Most  writers  include  fibroids  among  the  causes  of 
sterility,  but  differ  as  to  the  relative  importance  of  their  influence. 
Some  few  reverse  this  and  contend  that  the  fibroids  are  the  result 
of  the  sterility,  rather  than  the  cause.  If  this  were  so,  in  a  general 
sense,  then  the  most  fertile  women  would  show  the  smallest  num- 
ber of  fibroids,  but  one  of  tHe  most  fertile  races,  the  colored  race, 
is  also  most  prolific  in  fibroids,  so  much  so  in  fact,  that  the  great 
pathologist  Virchow  was  led  to  remark  "that  a  woman  of  this  race 


Fig.  17. — Schematic  Representation  of  Varieties  of  Fibroids  (Allbutt). 
mural,     b.,  submucous,     c,  subserous,     d.,  intra- uterine. 


a-a., 


without  a  fibroid  in  her  uterus  was  an  anomaly."  I  hardly  feel 
that  the  inference  that  fibroids  arise  because  the  normal  function 
of  the  uterus  is  in  abeyance  is  a  warrantable  one. 

If  there  is  one  thing  we  do  know  about  fibroids,  it  is  that  they 
grow  very  rapidly  in  pregnancy,  more  rapidly  than  at  any  other 
time,  and  that  after  the  pregnancy  is  over  they  decrease  in  size 
just  as  rapidly,  provided  inflammatory  or  degenerative  changes 
have  not  developed. 

Relation  of  Fibroids  to  Sterility  and  Fertility. — ^The  all-impor- 
tant point  in  the  question  of  the  relation  of  fibroids  to  sterility  and 
fertility  seems  to  me  to  be,  not  the  fact  of  their  presence,  but  of 
their  location  and  size.     The  submucous  fibroid  causes  bleeding 


128  STERILITY  AND   CONCEPTION 

and  a  thickened  endometrium,  which  tends  to  check  conception 
and  favors  the  production  of  abortion.  The  intramural  fibroid 
gives  rise  to  various  mechanical  obstacles  to  the  continuation  of 
pregnancy,  such  as  deformities  and  displacements  of  the  uterus, 
which  often  result  in  miscarriage.  Furthermore,  when  the  fibroid 
is  in  either  the  uterine  cavity  or  wall  of  the  uterus,  it  acts  as  a 
foreign  body  which  the  uterus  by  muscular  contraction  is  con- 
stantly endeavoring  to  expel.  Such  a  uterus,  in  a  more  or  less 
constant  state  of  tonic  contraction,  is  an  unfavorable  housing  for 
the  growing  ovum.  There  can  be  no  doubt  that  fibroids  in  the 
uterus  itself  play  an  important  role  in  inducing  miscarriage.  When 
the  tumor  has  been  expelled  from  the  uterus  and  becomes  sub- 
peritoneal, this  muscular  unrest  on  the  part  of  the  uterus  subsides 
and  the  fibroid  ceases  to  be  a  factor  in  the  production  of  abortion 
or  miscarriage.  From  now  on  the  mere  presence  or  size  of  the 
growth  has  little  to  do  with  the  causation  of  sterility,  but  its  loca- 
tion may  have  a  great  deal  to  do  with  the  successful  termination 
of  a  pregnancy,  for  when  located  in  the  pelvis,  even  though  it  be  of 
no  very  great  size,  it  can  greatly  complicate  or  actually  prevent 
delivery. 

The  promptness  with  which  conception  often  follows  the 
removal  of  fibroids  in  sterile  women  would  indicate  that  in  these 
cases  at  least  the  tumors  were  the  cause  of  the  sterility.  In  proof 
of  this  the  following  case  is  a  good  example: 


Mrs.  J.  H.  F.,  age  thirty-six,  was  married  one  year  without  ever  having  con- 
ceived. Menstruation  began  at  fourteen  years  of  age,  was  always  regular,  lasting 
eight  days,  and  was  very  profuse.  Slight  dysmenorrhea  had  developed  during  the 
year  of  married  life,  otherwise  she  was  free  of  symptoms  other  than  the  sterility. 

Examination  showed  an  enlarged  retroflexed  uterus.  The  enlargement  was 
irregular  in  character,  indicative  of  the  presence  of  small  fibroids.  At  operation, 
through  a  transverse  abdominal  incision,  four  of  these,  the  largest  two  inches  in 
diameter,  were  removed  from  the  various  parts  of  the  anterior  and  posterior 
uterine  walls.  A  larger  intra-uterine  fibroid  was  removed  from  the  uterine  cavity 
through  an  incision  made  in  the  anterior  uterine  wall.  Adhesions  between  the 
uterus,  adnexa,  and  rectum  were  separated,  the  uterus  replaced  and  the  round 
ligaments  shortened.  Conception  promptly  occurred  and  she  was  confined  at 
term  by  a  breech  delivery  of  a  living  child.  The  labor,  though  her  pains  were 
strong,  was  a  protracted  one,  lasting  twenty-one  hours.  The  child  weighed  six 
pounds,  one  and  one-half  ounces.  Her  second  confinement,  a  normal  eleven-hour 
labor,  resulted  in  the  birth  of  a  living  eight-pound  baby,  and  the  third  confinement, 
a  normal  five-hour  labor,  in  the  birth  of  a  living  child  weighing  eight  pounds  and 
fourteen  ounces. 


FIBROID   STERILITY  129 

Multiple  fibroids  of  the  uterus  are  attended  with  a  low 
degree  of  fertility,  but  it  is  not  unusual  for  their  removal, 
even  as  late  as  the  age  of  thirty-six,  to  result  in  a  cure  of 
the  sterility.  This  patient's  subsequent  obstetrical  history  is  a 
particularly  gratifying  triumph  for  enucleation.  Only  too  often  in 
these  cases  the  woman  is  deprived  of  all  hope  of  maternity  by  a 
hysterectomy,  radium,  or  X-ray  treatment.  Had  this  patient  been 
so  treated  the  world  would  have  been  a  very  dark  place  indeed  for 
her,  and  three  healthy  children  would  never  have  seen  the  light  of 
day.  Her  first  confinement,  a  protracted  breech  delivery,  with 
strong  labor  pains  for  twenty-one  hours,  within  less  than  one  year 
after  operation,  shows  how  firmly  the  incision  in  the  uterine  wall, 
through  which  the  fibroid  in  the  uterine  cavity  was  removed,  had 
healed. 

Too  much  importance  should  not  be  laid  on  the  accompanying 
retrodisplacement  in  this  case,  as  the  flexion  mentioned  was  a 
deformity  of  the  uterus  produced  by  the  fibroids  in  the  posterior 
wall,  and  the  posterior  position  of  the  fundus  was  more  in  the 
nature  of  a  sagging  due  to  increased  weight.  Years  of  exag- 
gerated muscular  activity  on  the  part  of  the  uterus  in  its  endeavors 
to  expel  the  fibroids  had  resulted  in  great  hypertrophy  of  its  walls. 
The  anterior  wall,  which  was  incised  in  order  to  remove  the  sub- 
mucous tumor  in  the  uterine  cavity,  was  two  and  one-half  inches 
thick.  When  all  the  tumors  had  been  enucleated  and  the  incision 
sutured,  the  breadth  of  the  uterus  was  greater  than  that  of  a  three- 
month  pregnancy,  yet  six  weeks  after  operation,  it  had  involuted 
to  nearly  normal  size. 

In  many  cases  of  sterility  the  fibroids  are  not  large  enough  to 
be  easily  felt  and  thus  may  not  be  suspected.  Again,  a  single 
fibroid  in  the  anterior  uterine  wall  at  the  fundus  can  give  the 
impression  of  an  anteflexion  and  lead  to  an  error  in  diagnosis,  as 
in  the  following  case : 

Mrs.  H.  D.,  thirty-three  years  of  age,  had  been  married  two  years  without 
ever  having  become  pregnant.  Menstruation  began  at  twelve  years  of  age,  and 
was  always  regular,  but  lasted  seven  days  and  was  very  profuse.  She  suffered 
from  only  slight  dysmenorrhea.  Two  recent  periods  had  been  prolonged  to  two 
and  three  weeks.     The  husband's  semen  was  normal. 

Examination  showed  an  anteflexed  uterus  with  a  small  fibroid  at  the  fundus. 
A  diagnosis  of  conditional  sterility  was  made.  At  operation  a  dilatation  and 
curettage  were  first  performed,  and  then  three  small  subperitoneal  fibroids  were 
removed  from  the  posterior  face  of  the  fundus,  and  one  intramural  fibroid  one 
inch  in  diameter  from  the  fundus  anteriorly.    This  later  was  beginning  to  become 


I30  STERILITY  AND  CONCEPTION 

submucous,  and  during  its  removal  the  uterine  cavity  was  opened.  The  right  ovary, 
being  large  and  cystic,  was  resected.  The  tubes  were  normal  and  probed  clear  into 
the  uterine  cavity.  Conception  occurred  during  the  first  few  months  after  opera- 
tion, and  she  was  delivered  at  term  of  a  Uving  child  less  than  one  year  after  her 
operation. 

This  patient  had  been  examined  by  a  number  of  careful  men 
previous  to  my  seeing  her  without  arousing  any  suspicion  on  their 
part  of  a  fibroid  as  being  responsible  for  the  sterility.  Again  I 
want  to  call  attention  to  the  fact  that  in  both  of  these  cases  of 
fibroid  sterility  just  cited  there  was  prolonged  and  profuse  men- 
struation gradually  increasing  in  severity  from  its  onset.  This 
symptom  can  usually  be  elicited  in  fibroid  cases,  even  though  the 
tumor  may  be  too  small  to  be  more  than  suspected.  It  affords  a 
valuable  clue  in  arriving  at  a  correct  diagnosis. 

The  following  case  history  presents  so  many  points  of  unusual 
interest  that  it  is  appended  as  a  noteworthy  exception  to  the  rule: 

The  patient,  Mrs.  H.  F.,  thirty-eight  years  old,  had  been  married  for  six 
years,  during  which  time  she  had  never  conceived.  Her  menstruation  was  normal, 
be^an  at  the  age  of  fourteen,  had  always  been  regular,  four  days  in  duration, 
moderate  in  amount,  with  slight  pain.  She  had  noticed  progressive  abdominal 
enlargement  with  increasing  tenderness  and  distress,  more  particularly  on  the  right 
side  of  the  abdomen,  for  the  past  nine  years.  When  the  enlargement  first  began 
she  was  advised  to  be  operated  upon  for  the  removal  of  multiple  fibroid  tumors. 
At  this  time  she  was  told  that  the  operation  would  be  one  of  extreme  seriousness, 
and  she,  therefore,  determined  to  go  as  long  as  she  could  without  it. 

Three  years  later,  shortly  after  her  marriage,  the  tumor  had  reached  nearly 
to  the  umbilicus,  and  surgical  advice  was  again  sought.  The  same  diagnosis  was 
made  and  the  same  treatment  advised  as  previously,  but,  as  she  was  very  anxious 
to  have  a  baby,  she  refused  to  consent  to  the  operation,  she  being  told  that  it  would 
in  all  probability  mean  the  removal  of  the  uterus. 

From  this  time  on  the  tumor  gradually  increased  in  size,  causing  more  and 
more  distress,  but  she  still  refused  operation,  in  the  hope  of  becoming  pregnant. 
Finally,  as  she  was  suffering  so  much,  and  as  pregnancy  had  never  occurred,  'she 
at  last  decided  to  submit  to  operation,  and  was  referred  to  me  by  her  physician. 

In  takmg  her  history  I  found  that  she  had  had  no  regular  menstrual  periods 
for  tv.-o  months — only  occasionally  slight  spotting.  Exammation  showed  marked 
protrusion  of  the  right  abdomen,  extending  from  the  symphysis  to  the  .free  border 
of  the  ribs,  slightly  to  the  left  of  the  median  hue,  and  around  behind  in  the  flank. 
As  far  as  one  could  determine  this  enlargement  was  due  to  a  hard  tumor,  slightly 
irregular  in  contour.  Vaginal  examination  showed  slight  bluing  about  the  introitus 
and  on  the  anterior  and  posterior  wall.  The  cervix  could  not  be  touched  or 
examined  with  the  speculum  because  of  the  extreme  degree  of  elongation  of  the 
vagina.  The  pelvis  was  nearly  filled  by  the  tumor,  and  no  portion  of  the  uterus 
could  be  felt.  The  vagina  was  crowded  against  the  left  side  of  the  pelvis.  Biman- 
ual examination,  at  the  best,  only  disclosed  a  smaller  tumor  to  the  left  of  the  large 
one — probably  the  uterus.  Auscultation  gave  no  fetal  heart  sounds,  but  a  marked 
bruit  in  the  left  lower  quadrant.     A  diagnosis  of  probable  pregnancy  was  made. 


FIBROID  STERILITY  .131 

and  the  case  kept  under  observation.  Because  of  the  upward  and  lateral  displace- 
ment of  the  uterus,  the  fibroid  was  considered  to  be  interligamentous. 

The  patient's  condition  was  little  changed  during  the  next  couple  of  weeks. 
At  the  end  of  that  time  morning  nausea  was  marked  and  she  thought  that  she  had 
once  or  twice  felt  life. 

On  the  5th  of  September  her  general  condition  was  slightly  improved.  The 
nausea  had  disappeared.  At  this  visit  her  abdominal  girth  was  39^  inches  at  the 
umbilicus,  and  the  greatest  circumference  40^  inches,  just  below  the  umbilicus. 
Her  weight  was  I57/^  pounds. 

On  October  19  she  felt  life,  and  the  fetal  heart  was  plainly  made  out  for  the 
first  time.  The  point  of  maximum  intensity  was  on  a  level  with  the  umbilicus,  six 
inches  to  the  left  of  the  median  line.  She  was  now  about  six  and  a  half  months 
pregnant,  and  her  maximum  abdominal  girth  was  still  only  40J/2  inches.  The 
uterus  could  now  be  quite  distinctly  mapped  out,  lying  entirely  above  the  brim  of 
the  pelvis,  in  close  proximity  to  the  tumor,  and  the  fundus  of  the  uterus  was  well 
under  the  free  border  of  the  ribs. 

From  this  time  until  December  i,  there  was  no  change  in  her  condition,  except 
that  considerable  dyspnea  developed,  so  that  she  was  unable  to  sleep  except  in  a 
semi-upright  position.    There  had  been  no  changes  in  the  urine,  which  was  normal. 

On  December  i  the  membrane  ruptured  spontaneously.  On  the  following  night 
her  pains  began.  She  was  delivered  through  a  median  line  incision,  extending 
above  and  below  the  umbilicus.  As  the  peritoneum  was  opened,  a  large  fibroid, 
interligamentous  in  character  and  intimately  adherent  to  the  uterus,  was  disclosed. 
A  great  venous  plexus  ran  across  from  the  fundus  of  the  uterus  to  the  tumor,  so 
that  it  was  with  some  difficulty  that  a  free  area  of  the  uterus  could  be  found  for 
incision.  Furthermore,  the  tumor  had  so  pressed  the  uterus  to  the  left  and 
twisted  it  posteriorly  that  the  incision  through  which  the  child  was  delivered  lay 
practically  to  the  side  of  the  uterus,  instead  of  in  front,  making  it  somewhat  diffi- 
cult to  deliver  the  baby.  Severe  hermorrhage  occurred  when  the  large  plexus  of 
veins  was  incised. 

A  girl-baby  weighing  five  pounds  and  five  ounces  was  delivered  in  a  stage  of 
pallid  asphyxia,  but  it  responded  promptly  to  artificial  respiration  and  survived. 

A  study  of  the  tumor  now  disclosed  the  fact  that  it  was  an  intraligamentous 
fibroid,  filling  the  pelvis  and  most  of  the  abdominal  cavity,  well  up  under  the  free 
border  of  the  ribs.  It  was  so  intimately  connected  with  the  uterus,  and  as  the 
uterus  also  contained  several  fibroids  in  addition,  it  was  thought  best  to  do  a  sub- 
total removal,  especially  as  the  patient  was  rather  a  poor  operative  risk.  When  the 
tumor  was  delivered,  the  patient  went  into  a  serious  collapse  for  a  few  moments, 
but  rapidly  recovered. 

In  freeing  the  large  fibroid,  during  removal  the  right  ureter  was  exposed  its 
whole  length  from  the  bladder  to  the  kidney,  but  at  only  one  point  was  it  entirely 
separated  from  the  surrounding  tissues. 

The  bed  of  the  tumor  was  so  extensive  that  the  amount  of  raw  surface 
exposed  was  something  appalling,  from  which  there  was  a  very  generous  oozing. 
The  poor  condition  of  the  patient  admitted  of  no  delay,  so  the  cavity  was  packed 
with  iodoform  gauze  brought  out  through  the  cervical  stump  into  the  vagina. 
Over  this  gauze  the  opening  in  the  broad  ligament  was  closed  and  the  abdominal 
wound  was  sutured  in  my  usual  manner. 

The  tumor  was  a  cystic  fibro-myoma  undergoing  degenerative  changes,  weigh- 
ing seventeen  founds  five  ounces. 

The  patient's  convalescence  was  uneventful.     The  maximum  temperature  was 


132  STERILITY  AND  CONCEPTION 

100  2/10,  with  a  pulse  of  120  reached  on  the  second  day.  It  then  subsided  to  nor- 
mal, with  a  pulse  of  88  on  the  fourth  day. 

No  milk  appeared  in  the  breasts,  and  the  baby  was  put  on  artificial  feeding, 
to  which  it  took  very  kindly. 

One  of  the  most  interesting  features  of  the  case,  from  a  medical  standpoint, 
was  the  fact  that  the  patient  went  from  her  fourth  month  of  pregnancy  to  nearly 
term,  with  less  than  one  inch  increase  in  her  abdominal  girth.  When  I  first  saw 
her,  the  abdomen  was  so  tense,  and  the  abdominal  cavity  so  completely  filled  by 
this  enormous  tumor,  that  it  was  hard  to  believe  that  she  could  possibly  continue 
with  her  pregnancy,  and  at  the  time  she  was  delivered  it  was  a  matter  of  the 
greatest  surprise  when  we  found  that  the  baby  was  actually  nearly  of  normal  size. 
That  the  abdomen  could  grow  a  pregnant  uterus  with  a  five  and  one-half  pound 
baby,  placenta,  and  amniotic  fluid  without  increasing  its  circumference  more  than 
one  inch  was  a  marvel  to  all  who  saw  the  case. 

The  baby  was  a  healthy  female  infant,  showing  no  deformity  other  than  a 
uniform  lateral  flattening  of  the  head,  the  biparietal  diameter  being  only  three  and 
one-half  inches.  Whether  this  shape  of  the  head  was  due  to  pressure  or  not,  I 
am,  of  course,  unable  to  say,  for  we  occasionally  meet  with  normal  cases  where 
the  same  peculiarly  shaped  head  is  present. 

The  pathological  report  on  the  tumor  was  fibromyoma,  undergoing  cystic 
degeneration. 

The  patient  was  discharged  from  the  hospital  six  weeks  after  operation  very 
much  improved  in  general  health,  having  gained  twelve  pounds  after  delivery. 

The  wound  united  by  primary  union,  and  the  cervical  stump  came  down  to  its 
normal  relation  to  the  vagina,  which  then  showed  no  undue  elongation. 

Myomectomy. — I  believe  that  the  mere  existence  of  a  fibroid 
tumor  situated  in  the  walls  of  the  uterus  or  in  the  uterine  cavity 
predisposes  to  sterility,  to  abortion,  to  other  dangers  of  the  preg- 
nant state,  and  to  a  lowered  fertility,  and  that  its  removal  is  indi- 
cated when  the  patient  is  in  a  reasonably  fertile  period  of  her  life 
and  desirous  of  bearing  a  child.  Myomectomy,  even  in  the  pres- 
ence of  multiple  tumors,  is  now  established  on  a  firm  footing  and 
should  always  be  the  operation  of  election  during  the  active  child- 
bearing  period  unless  strongly  contra-indicated.  When  the  opera- 
tion is  performed  for  sterility  in  suitable  cases  the  brilliancy  of 
results  is  really  dramatic,  as  in  the  cases  I  have  reported  above. 
The  success  which  has  attended  the  development  of  this  operation 
is  as  remarkable  as  it  is  deserved. 

The  nature  of  the  operation  for  uterine  myomata  will  naturally 
vary  according  to  the  situation  and  attachment  of  the  tumor. 
Simple  myomectomy  or  the  removal  of  the  tumor  without  any  of 
the  uterine  tissue  is  easy  of  performance  when  the  tumor  is 
encapsulated,  more  difficult  when  the  tumor  involves  the  sur- 
rounding muscular  tissue.  These  can  at  times  only  be  enucleated 
by  taking  away  as  well  more  or  less  of  the  uterine  tissue  with 


FIBROID   STERILITY  133 

which  the  tumor  is  incorporated  and  even  opening  into  the  uterine 
cavity,  as  occurred  in  two  of  the  cases  reported.  It  may  truly  be 
said  of  the  operation  of  myomectomy  that  the  exact  mode  of 
removal  can  never  be  decided  upon  until  the  abdomen  is  opened 
and  the  condition  ascertained  by  direct  inspection. 

When  the  enucleation  is  completed,  the  uterine  walls  should  be 
cleared  of  all  partially  detached  tissue  and  trimmed  so  as  to  snugly 
overlap  the  bed  from  which  the  growth  was  removed.  Rows  of 
buried  sutures  are  introduced  from  the  bottom  of  the  wound 
upwards,  in  succession,  so  as  to  completely  approximate  the  sides 
of  the  wound,  leaving  no  dead  space;  finally  the  peritoneal  sur- 
faces are  brought  together  by  a  superficial  running  stitch. 

LITERATURE 

Allbutt,  Playfair  and  Eden.    System  of  Gynecology.     1906. 
Chrobak,  R.     Beitrage  zur  Therapie  der  Uterusfibroids.     1871. 
Emmet,  T.  A.    Principles  and  Practice  of  Gynecology.     1884. 
Giles,  A.  E.    SteriUty  in  Women.     1919. 
Hart  and  Barbour.     Manual  of  Gynecology.     1905. 
Noble,  C.  P.    N.  Y.  Med.  Journ.     1906. 

Roberts,  C.  H.  Outlines  of  Gynecological  Pathology  and  Morbid 
Anatomy.     1901. 

Williams,  W.  R.    Uterine  Tumors.     1901. 


CHAPTER  XVIII 

SUBINVOLUTION  AND  SUPERINVOLUTION 

Subinvolution — Causal  factors — Symptomatology — Case  reports — Treatment — Super- 
involution,  puerperal  atrophy — Causal  factors — S3Tnptomatology— Diagnosis — 
Case   reports. 

Subinvolution  is  the  term  employed  to  designate  a  condition  of  the 
uterus  occurring  after  parturition  when  the  organ  is  left  in  an  enlarged 
and  congested  state,  not  having  returned  to  its  normal  size. 

After  delivery  the  uterus,  as  a  rule,  rapidly  decreases  in  size,  so  that 
by  the  end  of  the  lying-in  period  it  has  returned  to  normal  or  nearly 
normal  dimensions.  This  process  is  called  involution  and  is  generally 
complete  by  the  end  of  the  sixth  week  postpartum,  when  the  red  lochia 
has  ceased.  How  this  process  of  "involution"  is  brought  about  is  still 
open  to  question.  It  is  characterized  by  a  marked  and  rapid  reduction 
in  volume  of  the  muscular  tissue,  probably  brought  about  by  chemical 
action,  and  also  by  certain  difinite  changes  in  structure  as  well.  The 
contraction  of  the  muscular  walls  of  the  uterus  compresses  the  blood 
vessels,  many  of  which  are  thus  obliterated  and  eventually  disappear. 
The  parous  uterus  never  returns  to  quite  the  size  it  was  before  preg- 
nancy. 

The  characteristic  morbid  features  of  subinvolution  are  congestive 
enlargement  of  the  body  of  the  uterus  with  congestive  thickening  of 
the  endometrium.     The  cavity  of  the  uterus  is  also  increased  in  size. 

Subinvolution,  Causal  Factors. — Subinvolution  is  caused  by 
conditions  which  interfere  with  the  proper  muscular  contraction  in  the 
uterus  after  delivery,  such  as  weak  muscular  tone,  postpartum  hemor- 
rhage, retained  secundines,  and  infection.  Infection  is  a  very  fre- 
quent cause,  and  subinvolution  nearly  always  accompanies  postpartum 
pelvic  inflammation.  Lacerations  of  the  cervix  and  perineum  con- 
tribute toward  subinvolution  only  in  so  far  that  they  predispose  to 
infection. 

Symptomatology. — Subinvolution  generally  gives  rise  to  the 
characteristic  symptoms  of  pelvic  drag,  backaches,  and  menorrhagia, 

134 


SUBINVOLUTION  AND   SUPERINVOLUTION  135 

though  it  does  not  in  itself  produce  any  marked  disturbance  of  health. 
On  examination  the  uterus  is  found  larger  than  normal  and  more  or 
less  sensitive  to  direct  pressure. 

In  subinvolution  a  state  of  chronic  venous  congestion  exists,  which 
in  either  a  normally  situated  uterus  or  one  that  is  displaced  is  a  fre- 
quent cause  of  sterility  and  diminished  fertility.  The  very  definite 
pathological  changes  which  occur  in  the  uterus  itself  as  a  result  of  sub- 
involution vary  according  to  the  length  of  time  the  condition  has 
existed.  In  time  the  congestion  becomes  chronic,  leading  to  permanent 
changes  in  all  the  uterine  tissues.  The  most  serious  of  these  are  an 
increase  in  connective  tissues  in  the  uterine  walls  and  a  thickening  or 
overgrowth  of  the  endometrium,  known  as  "hyperplasia"  or  "hyper- 
trophy." This  change  in  the  endometrium  makes  of  it  an  unfit  soil 
for  the  growth  of  the  fertilized  ovum,  so  that  even  if  embedding  takes 
place  early  interruption  of  the  pregnancy  is  the  rule.  Many  women 
with  subinvolution  of  the  uterus  conceive  more  frequently  than  those 
where  this  condition  is  not  present,  because  their  pregnancies  end  in 
abortion,  but  after  the  condition  has  existed  for  several  years, 
incapacity  for  conception  eventually  arises  from  the  resulting  endo- 
metrial changes.  The  following  example  of  conditional  sterility  due 
to  postpartum  subinvolution  of  the  uterus  is  quite  typical  of  a  class  of 
cases  frequently  met  with: 

Mrs.  D.,  age  thirty-seven,  was  married  seven  years.  She  had  given  birth  to 
two  full-term  children;  the  last  delivery  was  five  years  before  she  consulted  me 
and  had  been  a  difficult  instrumental  one.  It  was  followed  by  an  infected  and 
prolonged  puerperium.  From  this  time  on  she  suffered  constantly  from  pelvic 
pain,  menorrhogia,  and  leukorrhea. 

Examination  showed  an  enlarged  subinvoluted  uterus  in  normal  position  and 
with  no  restriction  in  mobility,  but  markedly  tender  on  palpation.  The  uterus  was 
curetted,  removing  a  greatly  thickened  endometrium,  irrigated,  and  packed,  and 
her  convalescence  was  uneventful.  Prompt  relief  of  all  symptoms  followed,  men- 
struation taking  place  normally  for  the  first  two  months  after  operation.  During 
the  third  month  conception  occurred,  and  she  delivered  normally  at  term  of  a 
living  child. 

Treatment. — The  treatment  in  cases  of  subinvolution  where 
the  condition  has  only  existed  for  a  short  time  is  simple  and  limited  to 
a  daily  hot  douche  given  at  115°,  and  continued  for  twenty  minutes. 
Every  other  day  a  boroglyceride  or  ichthyol  and  glycerine  vaginal  tam- 
pon should  be  inserted  and  allowed  to  remain  for  twelve  hours. 

In  more  severe  cases  and  those  seen  only  after  the  disease  has 
existed    for    some   time   the   hypertrophied   endometrium    should    b^ 


136  STERILITY  AND  CONCEPTION 

removed  with  a  sharp  curette,  the  uterus  irrigated  and  then  tightly 
packed  with  iodoform  gauze.  The  gauze  is  allowed  to  remain  in  place 
for  three  days  to  stimulate  contractions  in  the  uterus,  and  involution 
may  be  further  hastened  during  this  time  by  administering  ergot  up  to 
full  physiological  tolerance. 

Puerpered  Atrophy  of  the  Uterus. — Superinvolution  of  the 
uterus,  or,  as  it  is  perhaps  better  designated,  puerperal  atrophy  of  the 
uterus,  is  a  rare  condition  where  following  childbirth  the  process  of 
involution  does  not  stop  when  the  uterus  has  reached  normal  size,  but 
goes  on  beyond  this  point,  leading  to  a  marked  degree  of  atrophy  in 
the  organ.  Sometimes  the  atrophy  is  slight  and  the  uterus  later  regains 
its  normal  size  and  functional  activity;  more  often  the  change  is  per- 
manent and  menstruation  never  reappears.  A  slight  degree  of  atrophy 
may  be  caused  by  lactation,  especially  prolonged  lactation,  but  this  is 
probably  physiological. 

Symptomatology. — In  superinvolution  the  uterus  is  decreased  in 
size,  its  walls  are  not  as  thick  as  normal,  and  the  endometrium  is  very 
thin  or  entirely  absent.  Severe  puerperal  infection  is  the  most  frequent 
cause  of  superinvolution,  but  it  should  be  borne  in  mind  that  there 
are  other  diseases  not  connected  with  the  puerperal  state,  such  as  myx- 
edema, tuberculosis,  Addison's  disease,  Graves's  disease,  and  insanity, 
to  which  may  be  added  great  emotional  distress,  that  can  cause  atrophy 
of  the  uterus  and  amenorrhea. 

Sterility  is  a  usual  accompaniment  of  superinvolution,  and  whereas 
the  latter  may  be  the  result  of  ovarian  atrophy,  no  pathological  changes 
in  the  ovaries  in  this  condition  have  ever  been  demonstrated. 

Diagnosis. — The  condition  of  atrophy  is  to  be  easily  diagnosed 
from  the  history  of  an  amenorrhea  dating  from  childbirth  and  per- 
sisting long  after  lactation  has  ceased.  Examination  will  show  a  small, 
hard  uterus  and  pale  cervix. 

Genuine  cases  of  puerperal  atrophy  of  the  uterus  are  of  such  rare 
occurrence  that  every  case  should  be  recorded.  The  following  case  is 
such  an  imusual  one  that  I  give  the  history  in  full: 

Mrs.  T.  S.,  age  thirty-eight  years.  Pari-i.  Following  an  uneventful  labor 
the  patient  developed  on  the  fifth  day  a  very  severe  auto-intoxication  from  retained 
lochia.  Following  this  there  was  an  absolute  agalactia.  She  menstruated  scantily 
a  few  times  during  the  year  after  delivery  and  then  stopped  entirely,  but  had  no 
other  unfavorable  sjmiptoms.  This  condition  continued  unchanged  for  ten  years, 
during  which  time  repeated  examinations  were  made,  alwaj's  disclosing  a  small, 
superinvoluted  uterus.  The  various  gland  derivatives  were  administered  at  dif- 
ferent times  during  this  period,  but  without  any  favorable  result. 


SUBINVOLUTION  AND  SUPERIN VOLUTION  137 

At  the  beginning  of  the  eleventh  year,  menstruation  reappeared,  there  being  a 
slight  show  for  two  days.  The  next  month  the  flow  was  more  profuse  and 
lasted  the  same  length  of  time-  The  third  month  she  had  a  normal  menstrual 
period,  moderate  in  amount,  lasting  five  days.  Conception  took  place  immediately 
after  this  period  and  she  was  delivered  at  term. 

I  have  tried  all  methods  of  treatment  in  cases  of  superinvolution 
and  am  obliged  to  confess  that  I  know  of  none  of  enough  value  to 
recommend  here. 


CHAPTER  XIX 

TUBAL  OCCLUSION 

Etiology  —  Route  of  infection  —  Catarrhal  conditions  -  -  Case  reports  —  Gonorrheal 
sterility— Acute  infections — Trauma — Case  report — Cases  of  doubtful  etiology. 

We  now  come  to  the  consideration  of  one  of  the  most  interesting 
types  of  sterility,  to  me  the  most  interesting  of  all:  those  of  tubal 
occlusion.  Just  how  frequently  tubal  occlusion  should  be  held  respon- 
sible for  sterility  is  still  a  question  much  under  discussion.  While  there 
are  some  who  teach  that  it  is  the  cause  in  only  a  small  percentage  of 
cases,  there  are  others  who  hold  it  accountable  for  a  great  majority. 
My  own  belief  is  that  it  plays  a  very  important  role  in  sterility,  and  in 
cases  of  absolute  sterility  is  one  of  the  most  important  factors  to  be 
considered.  I  know  of  no  way  to  definitely  determine  the  exact  per- 
centage, but  I  do  know  that  when  the  occlusion  is  bilateral  the  woman 
cannot  possibly  conceive,  and  that  in  such  cases  the  only  treatment 
which  offers  any  hope  of  a  relief  of  her  sterility  is  surgical. 

Etiology. — In  the  great  majority  of  cases,  tubal  occlusion  is 
the  result  of  inflammation  of  the  fallopian  tubes,  and  such  inflamma- 
tion is  in  an  overwhelming  number  of  instances  produced  by  gonor- 
rhea. The  ravages  of  this  disease  generally  so  seal  off  the  tubes  as  to 
make  conception  out  of  the  question.  Although  the  contents  of  the 
tube  may  be  absorbed,  spontaneous  reopening  of  the  fimbriated  end 
of  the  tube,  when  once  it  has  become  occluded,  almost  never  takes 
place,  and  surgical  measures  offer  the  only  hope  of  effecting  a  cure. 
Only  a  small  percentage  of  these  cases  of  closed  tubes  are  the  result 
of  outside  involvement,  such  as  might  result  from  the  spreading 
infection  of  an  appendicitis  or  from  an  attack  of  pelvic  peritonitis, 
resulting  from  a  postpartum  infection. 

Route  of  Infection. — The  path  by  which  the  infecting  organ- 
ism (gonococcus)  reaches  the  tube  lies  through  the  cervical  canal  and 
uterine  cavity.  The  disease  is  always  bilateral,  although  one  tube  may 
be  involved  for  some  little  time  in  advance  of  the  other.  The  structure 
of  the  tube  first  attacked  is  its  epithelial  lining,  the  disease  later  spread- 

138 


TUBAL  OCCLUSION  139 

ing  to  its  muscular  layers,  even  implicating  the  peritoneal  covering 
when  the  gonococci  can  be  found  in  all  coats  of  the  tube.  As  the 
infection  spreads  along  the  tube,  pus  begins  to  form,  and  by  the  time 
the  distal  end  is  reached  the  fimbria  become  drawn  into  the  lumen  of 
the  tube,  bringing  its  peritoneal  surfaces  together,  which  then  agglu- 
tinate and  close  the  tube. 

The  inflammation,  at  first  catarrhal  as  a  rule,  later  becomes  puru- 
lent, and  there  may  be  formed  an  abscess  of  the  tube.  This  is  known 
as  a  pyosalpinx  and  may  reach  so  large  a  size  as  to  even  rupture  spon- 
taneously or  as  the  result  of  trauma.  While  complete  absorption  of 
the  pus  rarely  takes  place,  cases  are  occasionally  met  with  where  the 
tube  is  left  with  only  a  small  amount  of  cheesy  exudate  in  its  interior 
and  with  greatly  thickened  walls.  Eventually  the  contained  pus  loses 
its  virulence,  the  pus  cells  disappear,  and  the  tube  is  left  considerably 
distended  with  a  clear  fluid,  while  its  walls  are  thin  and  almost  trans- 
parent (hydrosalpinx). 

Hydrosalpinx  is  not  very  common.  Gonorrheal  salpingitis  more 
usually  results  in  an  overproduction  of  connective  tissues  in  the  walls 
of  the  tube,  producing  a  permanent  deformity  with  constriction  and 
even  obliteration  of  the  tubal  canal. 

In  the  acute  stage  of  the  infection,  the  tube  is  very  friable,  tearing 
easily  on  the  least  traction  or  squeezing,  and  there  is  marked  edema 
present.  By  this  time  the  tube  is  usually  closed  off  and  becomes 
markedly  distended  as  the  amount  of  pus  increases.  Sometimes  the 
increase  in  tension  may  be  great  enough  to  force  open  either  end  of 
the  tube.  When  this  takes  place  at  the  distal  end,  it  always  results  in 
a  localized  peritonitis  and  occasionally  in  a  general  peritonitis  with  a 
fatal  termination.  When  occurring  at  the  proximal  end  the  drainage 
thus  established  through  the  uterus  usually  continues  until  a  cure  is 
effected. 

It  is  possible  to  restore  the  patency  of  occluded  tubes  by  operation, 
but  this  should  never  be  attempted  until  the  active  infection  is  long 
since  past.  Surgical  intervention  when  carried  out  at  the  proper  time 
need  not  necessarily  be  followed  by  a  reclosure,  as  adhesions  form  only 
in  the  presence  of  infection.  The  so-called  "club-tube"  is  generally 
taken  to  be  typical  of  gonorrhea  and  is  easily  recognized.  It  is  often 
seen  free  from  adhesions,  has  an  expanded  and  smooth  distal  end 
showing  no  opening,  and  no  fimbriae.  The  latter  lie  inside  the  tube 
where  they  were  drawn  at  the  beginning  of  the  infection.  If  this  end 
of  the  tube  be  now  carefully  studied,  it  is  usually  possible  to  detect  a 


I40  STERILITY  AND  CONCEPTION 

small  depression,  the  "gonorrheal  dimple,"  at  some  point  which  denotes 
the  site  of  the  original  opening.  Rarely  is  occlusion  found  in  the 
middle  third  of  the  tube  and  practically  never  in  the  proximal  end. 
I  have  only  once  met  with  a  complete  obliteration  of  the  lumen  of  the 
tube. 

The  following  case  is  an  excellent  example  of  gonorrheal  sterility 
cured  by  operation: 

Mrs.  R.,  when  I  first  saw  her,  was  thirty-two  years  old.  Menstruation  had 
begun  at  the  age  of  twelve,  was  irregular,  lasting  four  days  and  unaccompanied 
by  pain.  She  had  been  married  for  eight  years,  during  all  of  which  time  conception 
had  never  occurred.  At  the  outset  of  her  married  life  her  husband  had  infected 
her  with  gonorrhea,  which,  accompanied  by  a  severe  pelvic  peritonitis,  had  run  its 
typical  course.  Over  a  number  of  years  she  had  suffered  from  frequent  subacute 
exacerbations,  and  from  the  very  first  attack  there  had  been  marked  changes  in 
her  menstruation,  which  was  accompanied  by  menorrhagia,  dysmenorrhea,  back- 
aches, pelvic  pain,  and  nervousness,  all  increasing  in  severity. 

On  examination  she  was  found  to  have  a  rather  small  uterus,  anterior  in  posi- 
tion and  much  restricted  in  mobility.  The  right  adnexa  were  enlarged  and 
adherent ;  the  left  prolapsed  and  also  enlarged  and  adherent ;  both  were  tender 
on  palpation.  At  operation  on  April  lo,  1903,  in  her  home,  the  pelvic  condition  was 
approached  through  an  anterior  vaginal  incision,  but  on  opening  the  peritoneal 
cavity  was  found  much  too  extensive  to  treat  by  this  route.  The  abdomen  was 
therefore  opened,  when  the  following  condition  was  revealed: 

Both  ovaries  were  small  and  buried  with  the  tubes  in  extensive  velementous 
adhesions  which  held  them  fast  to  the  broad  ligaments,  posterior  face  of  the  uterus, 
and  rectum.  These  adhesions  were  separated,  and  the  tubes  and  ovaries  released. 
On  inspecting  the  tubes,  they  presented  the  typical  club  formation  with  closed 
extremities.  Upon  cutting  the  left  tube,  its  lumen  was  found  completely  obliter- 
ated, and  the  entire  tube  was  removed.  The  accompanying  ovary  had  been  so 
mutilated  during  the  process  of  freeing  that  it  was  also  removed.  The  right  tube, 
after  opening  its  distal  end,  was  found  to  have  a  patent  lumen  which  could  be 
probed  into  the  uterine  cavity.  As  this  end  was  torn  and  ragged  from  the  separa- 
tion of  adhesions,  about  one  inch  of  it  was  removed  and  a  plastic  reconstruction 
carried  out.  Subsequent  convalescence  proved  uneventful ;  there  was  a  marked 
improvement  in  all  sj'mptoms;  menstruation  became  regular  and  painless. 
Eighteen  months  after  the  operation  she  gave  birth  at  term  by  a  normal  delivery 
to  an  eight-pound  baby,  and  again  eighteen  months  later  to  another.  Both  children 
are  living  and  well. 

This  case  was  one  of  the  most  instructive  in  my  series,  and  had  the 
patient  not  been  separated  from  her  husband  after  the  birth  of  the 
second  child,  might  have  been  one  of  the  most  productive.  The  patho- 
logical picture  presented  at  the  time  of  operation  was  typical  of  the 
ravages  of  gonorrhea  when  once  the  infection  gains  access  to  the 
pelvic  organs. 

The  complete  embedding  of  the  ovaries  prevented  the  release  of 
the  ova  which,  even  had  escape  been  possible,  could  not  have  been  taken 


TUBAL  OCCLUSION  141 

up  by  the  tubes  in  their  occluded  condition.  Yet  observe  the  lightning- 
like rapidity  with  which  conception  occurred  when  once  the  path  to  the 
uterus  had  been  cleared  of  obstruction — eight  years  of  suffering  and 
sterility,  operation  with  a  cure  of  all  symptoms,  and  successful  deliv- 
ery within  eighteen  months. 

This  woman  was  absolutely  sterile,  as  are  countless  numbers  of 
others  who  are  operated  upon  every  year,  where  a  radical  removal  of 
the  pelvic  organs  is  always  the  operation  of  election,  at  which  no 
attempt  is  ever  made  to  conserve  the  child-bearing  function  of  the 
woman.  First  infected  by  her  husband  and  then  robbed  of  all  hope 
of  maternity  by  her  surgeon,  she  is  left  a  pathetic  figure  in  society,  a 
martyr  to  radical  surgery. 

Another  typical  case  of  gonorrheal  sterility  was  the  following: 

Mrs.  L.  K.  when  first  seen  was  thirty-three  years  of  age,  had  always  enjoyed 
good  health,  and  her  menstruation,  which  began  at  the  age  of  fourteen,  was  regular, 
lasting  four  days,  scanty  in  amount,  but  painless.  She  had  been  married  two  and 
one-half  years  without  having  conceived.  Shortly  after  her  marriage  she  suffered 
an  acute  attack  of  abdomino-pelvic  peritonitis  followed  by  a  slow  convalescence 
and  a  persistence  of  the  pelvic  pain.  Menstruation  became  irregular,  painful,  and 
profuse,  at  times  lasting  for  two  weeks. 

On  examination  she  was  found  to  have  a  rather  small,  anteflexed  uterus,  which 
was  tender  on  palpation  and  slightly  restricted  in  mobility.  In  examining  the 
adnexa,  no  marked  enlargement  could  be  made  out,  but  there  was  considerable 
tenderness  present  on  both  sides.  At  operation  on  August  10,  1916,  in  the  Poly- 
clinic Hospital,  both  adnexa  were  found  to  be  adherent  to  the  posterior  face  of 
the  broad  ligament  with  here  and  there  an  adherent  tab  of  omentum.  Both  tubes 
were  closed,  terminating  in  characteristic  clubbed  ends.  The  left  tube  was  a  large, 
flaccid  hydrosalpinx,  surrounding  and  densely  adherent  to  an  enlarged  cystic  ovary. 
As  these  appendages  seemed  hopelessly  diseased,  they  were  removed  entire.  When 
the  right  adnexa  were  separated  from  adhesions,  the  ovary  appeared  quite  normal 
and  was  not  further  disturbed.  The  tube  was  opened  at  the  gonorrheal  dimple  and 
the  fimbriae  released.  Then  with  some  difficulty,  because  of  the  greatly  exaggerated 
kinks  and  tortuous  course  of  the  tube,  the  probe  was  finally  passed  into  the 
uterine  cavity.  Convalescence  was  uneventful.  Conception  occurred  during  the 
third  month  after  operation,  and  she  was  delivered  at  term  of  a  living  child. 

Another  case  of  gonorrheal  closure,  but  presenting  a  rather  dif- 
ferent picture  follows: 

Mrs.  P.  R.,  thirty-two  years  of  age,  who  had  been  married  four  years  without 
having  conceived ;  menstruation  had  always  been  normal  before  marriage,  but 
afterwards  she  had  developed  dysmenorrhea,  backaches,  and  pelvic  pain. 

When  she  was  examined,  the  uterus  was  found  retroflexed,  enlarged,  and 
adherent.  At  the  fundus  there  was  an  intramural  fibroid  about  two  inches  in 
diameter  with  two  smaller  subperitoneal  ones  near  by.  At  operation  on  May  31. 
1918,  in  the  Polyclinic  Hospital,  the  presence  of  the  fibroids  was  verified  and  the 


143  STERILITY  AND  CONCEPTION 

adnexa  of  both  sides  found  adherent  with  the  uterus.  Both  tubal  extremities  were 
closed.  The  adhesions  were  extensive  and  firm,  so  that  considerable  difficulty  was 
encountered  in  separating  the  tubes.  The  left  tube  was  extensively  damaged  during 
the  process  of  separation.  As  it  could  not  be  probed  after  opening  the  distal  end, 
it  was  removed.  The  right  tube  was  opened  with  little  difficulty  at  the  seat  of 
the  gonorrheal  dimple  and  freely  probed  into  the  uterine  cavity.  Both  ovaries  were 
normal  in  appearance.  The  uterus,  which  had  been  freed  from  adhesions,  was 
replaced,  the  fibroids  removed,  and  the  round  ligaments  shortened.  Convalescence 
was  uneventful. 

After  operation  all  her  unfavorable  menstrual  symptoms  were  cured;  she 
conceived  during  the  eleventh  month  following  and  was  delivered  of  a  living  child 
at  term. 

In  the  above  case  there  were  two  well-recognized  causes  of  relative 
sterility  present :  adherent  retroflexion  and  an  intra-nrural  fibroid, 
with  one  of  absolute  sterility,  tubal  occlusion.  Such  a  combination  of 
etiological  factors  in  the  same  case,  any  one  of  which  was  enough  to 
have  caused  the  sterility,  is  rather  unusual,  and  that  Nature  should 
have  responded  so  promptly  after  the  handicap  was  removed  was 
extremely  gratifying  and  encouraging. 

Acute  Infections. — Another  type  of  tubal  occlusion  sterility 
cases  frequently  encountered  is  that  caused  by  acute  septic  infection 
resulting  from  abortion,  miscarriage,  or  labor.  In  these  the  etiological 
factor  may  be  either  the  staphylococcus  or  the  streptococcus.  These 
reach  the  tube  by  direct  extension  along  the  lining  membrane  of  the 
uterus,  set  up  an  inflammatory  reaction,  and  the  resulting  salpingitis 
leads  to  closure  of  the  tube  at  some  point  or  other,  usually  at  the  distal 
end.  The  closed  end,  however,  is  not  found  sealed  off  with  a  free, 
club-like  extremity  and  gonorrheal  dimple,  as  is  seen  in  the  specific 
cases,  but  is  usually  matted  and  densely  adherent  to  neighboring  struc- 
tures. 

In  another  class  of  these  postpartum  cases,  the  infection  gains 
entrance  through  some  traumatism  of  the  birth  canal,  such  as  lacera- 
tions of  the  vulva,  perineum,  vagina,  or  cervix,  and  travels  through  the 
lymphatics,  producing  in  the  course  of  the  disease  a  local  or  pelvic 
peritonitis.  Here  the  tubes  resting  on  the  inflamed  peritoneal  surface 
become  involved  secondarily  by  continuity,  and  the  plastic  exudate 
thrown  out  as  a  result  of  the  peritonitis  closes  their  fimbriated  ends. 

This  condition  was  well  instanced  in  the  following  case: 

Mrs.  A.  C,  nineteen  years  of  age,  was  always  well  and  gave  no  history  of  any 
venereal  disease.  Menstruation  began  at  the  age  of  fourteen,  irregular,  three 
days'  duration,  moderate  in  amount  and  accompanied  by  slight  pain.  She  had  been 
married   for  three  and  one-half  years.     Some  time  after  marriage  she  had  an 


TUBAL  OCCLUSION  143 

abortion  at  six  months,  which  was  followed  by  an  attack  of  pelvic  peritonitis  and 
a  protracted  febrile  convalescence.  Recovering  from  this,  she  was  left  with  more 
or  less  constant  abdomino-pelvic  pain,  more  marked  on  the  left  side,  and  had  never 
again  become  pregnant.  The  sterility,  when  I  first  saw  her,  was  of  two  years' 
standing. 

Examination  at  this  time  disclosed  an  anteflexed  uterus  with  very  definite 
restriction  in  mobility.  The  slightest  attempt  at  manipulation  caused  much  pain. 
The  right  adnexa  were  negative;  the  left  were  enlarged,  prolapsed,  adherent,  and 
tender.  At  operation,  on  September  17,  1910,  at  the  Polyclinic  Hospital,  the 
appendages  of  both  sides  were  found  to  be  prolapsed  and  adherent.  Both  tubes 
were  Closed  at  their  distal  ends  by  adhesions,  while  the  ovaries,  which  were  only 
slightly  adherent,  appeared  otherwise  normal.  All  adhesions  were  freed.  The 
tubes  were  opened  and  probed  into  the  uterine  cavity.  Convalescence  was 
uneventful. 

S^e  was  delivered  eleven  months  later,  at  seven  and  one-half  months,  of  a 
livii;g(fchild. 

The  infection  responsible  for  the  tubal  closure  in  this  patient  had 
undoubtedly  gained  an  entrance  through  some  lesion  of  the  lower 
genitalia  and  traveled  up  the  lymphatics,  causing  a  pelvic  peritonitis, 
for  the  tubes  themselves  presented  no  evidence  of  a  previous  inflam- 
matory involvement,  with  the  single  exception  of  their  fimbriated  ends. 
These  were  closed  by  adhesions  to  the  pelvic  peritoneum  where  they 
had,  in  all  probability,  become  agglutinated  at  the  time  of  the  acute 
puerperal  infection.  After  the  tubes  were  released  they  appeared  quite 
normal,  so  that  any  resection  or  reconstruction  was  unnecessary. 

A  case  of  tubal  occlusion  of  doubtful  etiology  follows: 

Mrs.  E.  T.,  twenty-four  years  of  age.  She  had  always  been  well  and  denied 
any  venereal  infection  either  before  or  after  her  marriage,  which  had  been  nine 
years  previous.  Menstruation  began  at  the  age  of  twelve,  was  regular,  lasting  six 
days,  moderate  in  amount  and  painless.  Within  two  years  after  marriage  her  first 
and  only  child  was  born  by  a  normal  delivery,  followed  by  an  uneventful  puer- 
perium.  After  this  she  had  never  conceived  again,  though  very  anxious  for 
another  child.  Marked  changes  in  menstruation  developed,  the  flow  becoming  of 
longer  duration  and  quite  painful.  In  addition,  she  now  suffered  from  backaches 
and  occasional  pelvic  pain.  Her  chief  complaint,  however,  was  the  sterility  of 
seven  years'  standing. 

Examination  showed  a  slight  laceration  of  the  cervix,  but  no  evidence  of  any 
inflammation.  The  uterus  was  normal  in  size  and  position,  but  markedly  restricted 
in  mobility.  The  appendages  on  both  sides  were  slightly  enlarged,  prolapsed, 
adherent,  and  tender.  At  operation  on  October  15,  1910,  at  the  Polyclinic  Hospital, 
the  adnexa  of  both  sides  were  found  to  be  prolapsed  and  adherent  to  the  pelvic 
peritoneum  posteriorly.  The  tubes  were  closed  but  otherwise  presented  no  gross 
evidence  of  disease.  The  ovaries  appeared  normal.  All  adhesions  were  easily 
separated,  the  tubes  opened  and  probed  into  the  uterine  cavity.  Convalescence  was 
uneventful.  Conception  promptly  resulted,  and  she  was  delivered  at  term  of  a 
living  child  ten  months  after  operation. 


144  STERILITY  AND  CONCEPTION 

As  has  been  said,  the  source  of  infection  in  this  case  was  uncertain, 
careful  inquiry,  several  times  repeated,  failed  to  elicit  any  history  of  a 
previous  gonorrhea,  nor  could  she  recall  any  details  of  her  puerperium 
that  would  indicate  an  infection  at  that  time.  It  is  more  than  probable 
that  this  infection  was  of  puerperal  origin,  which  would  conform  with 
the  clinical  findings  at  the  time  of  operation.  The  rapidity  of  the  cure 
in  this  case  was  almost  startling.  Seven  years  of  sterility,  operation 
and  successful  delivery  within  ten  months ! 

Another  instructive  case  of  postpartum  closure  was  the  following: 

Mrs.  L.  v.,  twenty-seven  years  of  age.  Menstruation  began  at  the  age  of 
fourteen,  irregular,  lasting  ten  days,  most  profuse  and  with  considerable  pain.  She 
had  been  married  for  eight  years.  During  that  time  had  had  one  miscarriage  and 
given  birth  to  two  children  at  term  by  normal  deliveries,  the  last  child  being  born 
four  years  previously.  At  the  last  confinement  she  had  been  infected  and,  though 
extremely  anxious  for  more  children,  had  never  conceived  again.  She  suffered 
constantly  from  menorrhagia,  dysmenorrhea,  and  pelvic  pain. 

Examination  showed  a  uterus  normal  in  size  and  position,  but  with  marked 
restriction  in  mobility.  The  adnexa  of  both  sides  were  slightly  enlarged  and  tender 
on  palpation,  but  no  adhesions  could  be  made  out.  At  operation,  on  October  2T, 
1916,  at  the  City  Hospital,  the  adnexa  were  found  to  be  adherent  to  the  broad 
ligaments  and  to  the  uterus.  The  ovaries,  when  separated  from  the  adhesions, 
appeared  to  be  normal,  but  both  tubes  were  considerably  thickened  throughout  their 
whole  extent  and  occluded  at  their  distal  ends.  On  opening  the  tubes,  the  right 
could  be  probed  free  into  the  uterine  cavity.  The  left  was  obliterated  in  its  middle 
third,  and  the  probe  could  not  be  made  to  pass  the  obstruction.  This  obliterated 
portion  was,  therefore,  removed,  and  the  distal  portion  anastomosed  to  the  proximal 
over  an  inlay  of  large-size  kangaroo  tendon;  the  idea  of  the  tendon  inlay  being  to 
keep  the  tubal  canal  patent  until  the  anastamosis  had  united.  Convalescence  was 
uneventful.  Following  the  operation  she  was  relieved  of  the  pelvic  pain  and 
menstruated  normally  for  two  years  and  eleven  months.  Conception  occurred  and 
she  was  delivered  by  a  normal  labor  at  term. 

The  delay  in  conception  in  this  case  was  probably  due  to  the  fact 
that  the  tubes,  being  considerably  thickened  at  the  time  of  operation, 
the  result  of  extensive  disease  in  the  past,  did  not  function  until  the 
chronic  inflammation  had  cleared  up.  Such  a  marked  thickening  of 
the  tubes  as  existed  in  this  case  pointed  to  a  direct  infection  from  the 
uterine  cavity,  rather  than  to  invasion  by  the  lymphatics.  Whether 
conception  in  this  case  took  place  through  the  anastamosed  tube  or  not 
could  not  be  determined,  and  probably  never  will  be.  Personally  I 
have  never  been  able  to  trace  a  cure  of  sterility  to  this  operative  pro- 
cedure, though  I  have  used  it  numerous  times,  but  several  are  reported 
in  the  literature  that  give  me  hope  of  ultimate  success. 

The  next  case  is  one  of  more  than  passing  interest,  and  is  so 


TUBAL  OCCLUSION  145 

instructive  that  I  place  it  under  this  head,  though  the  etiology  was 
uncertain. 

Mrs.  C.  B.,  twenty-eight  years  of  age.  Menstruation  began  at  the  age  of 
sixteen,  was  always  regular,  lasting  four  days,  moderate  in  amount  and  painless. 
She  had  been  married  three  years  and  had  first  conceived  on  her  honeymoon.  This 
pregnancy  was  interrupted  at  two  months  and  she  did  not  conceive  again  for  two 
and  one-half  years.  It  was  with  this  second  pregnancy  that  I  first  saw  her.  She 
gave  a  history  of  ten  weeks'  amenorrhea  and  presented  all  the  clinical  symptoms 
of  unruptured  ectopic  pregnancy. 

Examination  showed  the  uterus  anterior  in  position,  slightly  enlarged,  tender, 
and  with  marked  restriction  in  mobility.  Both  tubes  were  enlarged  and  tender. 
The  right  was  much  larger  than  the  left,  prolapsed  but  not  adherent.  She  had 
been  curetted  on  a  diagnosis  of  incomplete  abortion  some  weeks  before.  At  opera- 
tion on  November  21,  1918,  at  the  New  York  Nursery  and  Child's  Hospital,  a  large 
unruptured  right  tubal  pregnancy  was  removed,  together  with  an  adherent  con- 
gested appendix.  On  inspecting  the  left  tube  it  was  found  to  be  prolapsed,  slightly 
adherent,  and  closed  at  its  distal  end.  After  separating  the  adhesions  it  was 
opened  and  probed  into  the  uterine  cavity.  Both  ovaries  were  normal  in  appear- 
ance and  were  not  disturbed  other  than  to  free  them  from  slight  adhesions. 
Convalescence  was  uneventful.  Conception  promptly  occurred  and  she  was  deliv- 
ered at  term  by  a  normal  labor  of  a  living  child  in  less  than  one  year  after  opera- 
tion. Within  six  months  she  again  conceived,  but  I  have  been  unable  to  learn  the 
outcome  of  this  pregnancy. 

The  nature  of  the  infection  in  this  case  was  uncertain,  but  as  only 
one  tube  was  occluded,  it  is  more  than  probable  that  it  resulted  from 
infection  at  the  time  of  the  induced  abortion  shortly  after  marriage. 
Although  the  patient  was  pregnant  in  the  right  tube  at  the  time  of 
operation,  I  have  included  her  in^this  series  because,  with  the  removal 
of  the  right  tube  in  the  presence  of  the  occluded  left,  she  became  a  case 
of  absolute  sterility  and  would  have  so  remained  had  the  occlusion  of 
the  remaining  tube  not  been  relieved.  This  case  is  a  good  illustration 
of  the  importance  of  always  examining  the  opposite  tube  when  oper- 
ating for  tubal  pregnancy,  not  only  because  of  the  possibility  of  the 
existence  of  a  bilateral  tubal  pregnancy,  but  because  the  remaining  tube 
may  be  occluded  and  the  woman  left  hopelessly  sterile  unless  the  occlu- 
sion is  relieved. 

LITERATURE 

Child,  Jr.,  C.  G.  Sterility  in  the  Female.  Trans.  Am.  Gyn.  Soc. 
1920. 

PoLAK,  J.  O.     Pelvic  Inflammation  in  Women.     192 1. 
Pryor,  W.  R.    Text  Book  of  Gynecology.     1903. 


CHAPTER  XX 
CONTRACEPTIVES 

GENERAL  REMARKS  IN  REGARD  TO  BIRTH  CONTROL 

Prevention  of  conception  is  a  very  common  practice  among  civil- 
ized people  of  the  present  day.  Practiced  clandestinely  and  in  a  small 
way  probably  from  the  beginning  of  all  time,  it  is  now  so  widespread 
as  to  threaten  the  very  survival  of  the  race.  The  movement  has  lately 
grown  by  leaps  and  bounds,  obtaining  frequent  mention  in  the  public 
press  and  even  from  the  pulpit.  This  has  led  to  the  almost  wholesale 
establishment  of  "birth-control"  societies  holding  public  meetings  and 
regularly  publishing  official  organs  for  the  wider  dissemination  of  their 
infamous  propaganda. 

One  of  the  greatest  authorities  on  sterility,  Dr.  Englemann,  has 
stated  it  as  his  belief  "that  the  avoidance  or  the  prevention  of  concep- 
tion if  possible,  the  premature  termination  of  pregnancy  if  need  be, 
are  factors  far  more  potential  of  causation  of  decreasing  fecundity 
than  is  the  progress  of  gynecic  science  to  the  contrary." 

At  this  point  I  should  like  to  stop  for  a  moment  and  review  some 
of  the  principal  arguments  advanced  by  the  advocates  of  birth-control 
in  favor  of  their  movement.  In  one  of  their  recently  published  books 
we  find  the  following  summary  of  woman's  position  in  the  world 
to-day.  "Women  in  all  land  and  all  ages  have  instinctively  desired 
family  limitation.  It  has  been  manifested  in  such  horrors  as  infanti- 
cide, child  abandonment,  and  abortion.  The  only  term  sufficiently 
comprehensive  to  define  this  motive  power  of  woman's  nature  is  the 
feminine  spirit.  That  spirit  manifests  itself  most  frequently  in  mother- 
hood, but  it  is  greater  than  maternity.  Woman  herself,  all  that  she 
is,  all  that  she  has  ever  been,  ail  that  she  may  be,  is  but  the  outworkings 
of  this  inner  spiritual  urge.  Woman's  desire  for  freedom  is  born  of 
the  feminine  spirit,  which  is  the  absolute,  elemental,  inner  urge  of 
womanhood.  It  is  the  strongest  force  in  her  nature;  it  cannot  be 
destroyed;  it  can  merely  be  diverted  from  its  natural  expression  into 

146 


CONTRACEPTIVES  147 

violent  and  destructive  channels.  The  chief  obstacles  to  the  normal 
expression  of  this  force  are  undesired  pregnancy  and  the  burden  of 
unwanted  children.  Driven  by  the  irresistible  force  within  them,  they 
will  always  seek  wider  freedom  and  greater  self -development,  regard- 
less of  the  cost." 

It  would  be  difficult  to  find  a  more  untruthful  statement  of  woman's 
past  or  a  more  hopeless  prophecy  of  her  future  than  is  contained  in 
the  above  quotation  from  one  of  their  recent  publications.  The  true 
woman,  the  one  deserving  of  the  name,  has  always,  in  all  times  and  in 
all  lands,  instinctively  desired  children.  If  she  has  felt  the  "inner 
urge"  tempting  her  to  family  limitation,  she  has  bravely  stifled  it  and 
nobly  continued  in  the  right  path,  a  glory  to  her  sex,  her  country,  and 
her  Creator.  It  has  been  well  for  the  world  that  such  women  have 
predominated,  and  it  is  to  be  devoutly  hoped  that  they  will  continue  to 
predominate  throughout  all  ages.  The  number  that  have  practiced 
infanticide,  child  abandonment,  and  abortion  have  been  few  in  com- 
parison, or  we  should  have  long  since  passed  into  oblivion.  To  call  the 
motive  power  that  may  tempt  a  woman  to  practice  birth-control  by  the 
use  of  contraceptives  or  to  kill  or  abandon  her  child  the  "feminine 
spirit"  and  to  rate  it  as  greater  than  the  maternal  spirit  is  such  a  base 
slander  of  womanhood  that  I  marvel  her  sex  has  been  so  slow  in  resent- 
ing it.    All  honor  to  the  few  who  have. 

Again,  turning  to  the  same  source  of  misinformation,  or  rather 
malinformation,  quoted  above,  we  find  the  following:  "Excessive 
child-bearing  is  now  recognized  by  the  medical  profession  as  one  of  the 
most  prolific  causes  of  ill  health  in  women.  There  are  in  America 
hundreds  of  thousands  of  women,  in  good  health  when  they  married, 
who  have  within  a  few  years  become  physical  wrecks,  incapable  of 
mothering  their  children,  incapable  of  enjoying  life."  But  who  is  to 
decide  the  question  of  what  constitutes  excessive  child-bearing  for  the 
individual  woman  ?  Certainly  not  the  lay  woman  writer  or  the  woman 
herself.  Better  leave  the  question  to  the  physician  to  decide,  or  should 
procreation  then  be  stopped  altogether  in  the  interest  of  these  com- 
paratively few  thousands?  Would  it  not  be  better  to  decide  on  the 
fitness  of  the  man  and  woman  before  marriage,  to  so  guard  the 
woman  that  she  will  not  have  to  reap  the  harvest  of  his  "wild  oats" 
or  become  the  victim  of  ignorant  obstetrics  when  her  children  are 
born,  both  such  prolific  causes  of  marital  ill  health? 

"Each  and  every  unwanted  child,"  says  the  same  "authority,"  "is 
likely  to  be  in  some  way  a  social  liability.     It  is  only  the  wanted  child 


148  STERILITY  AND  CONCEPTION 

who  is  likely  to  be  a  social  asset. "  Splendid !  Then  we  shall  indeed 
return  to  the  good  old  days  of  superstition  and  credulity,  of  astrology 
and  chiromancy,  when  they  and  their  kindred  "sciences"  shall  cast  the 
horoscope  of  the  unborn,  yes,  even  unconceived  child,  and  be  called 
upon  to  decide  as  to  whether  it  will  be  a  social  asset  or  liability.  There 
will  then  be  many  anxious  potential  mothers  busily  engaged  with  retort 
and  crucible,  for  even  the  possession  of  a  powerful  and  over-mastering 
intellect  such  as,  according  to  their  high  priestess  of  birth-control, 
these  women  will  possess,  will  afford  no  trustworthy  safeguard  against 
the  assaults  of  credulity.  There  has  been  no  era  in  the  world's  history 
when  superstition  has  not  found  a  congenial  soil  in  the  human  mind, 
and  these  "super-women"  will  prove  to  be  no  exception. 

I  have  made  an  attempt  to  analyze  some  of  the  utterances  of  the 
birth-control  propagandist,  but  I  use  the  word  "attempt"  advisedly,  for 
he  would  be  a  bold  man  indeed  who  would  pretend  to  grasp  their 
meaning  or  try  to  clothe  such  a  system  of  demonology  with  even  a 
plausible  appearance  of  intelligibility.  When  you  listen  to  the  ravings 
of  delirium  you  often  wonder  whether  or  not  you  are  in  full  possession 
of  your  judgment,  and  in  talking  with  a  madman  you  often  feel  your 
own  reason  begin  to  totter.  An  honest  effort  to  find  a  grain  of  sense 
in  such  a  heap  of  rubbish,  or  to  trace  a  single  constructive  thought 
amid  such  a  parade  of  ratiocination,  leaves  the  brain  in  a  state  of  hope- 
less stupor  from  the  very  confused  progress  of  words. 

The  almost  world-wide  movement  of  birth-control  is  purely  a 
social  development  conducted  principally  by  women  among  whom  the 
"detached  woman"  is  most  conspicuous,  as  a  revolt  against  their 
fancied  sex  servitude ;  it  is  the  means  by  which  they  hope  to  attain  the 
basic  freedom  of  their  sex.  Fortunately,  the  demand  for  birth-control 
is,  as  yet,  limited  to  a  small  but  noisy  minority. 

The  possible  increase  in  population  beyond  the  bounds  of  the 
nation's  ability  sufficiently  and  properly  to  feed  has  caused  great  alarm 
among  many  thoughtful  students  of  this  question,  making  of  them 
advocates  of  birth-control.  But  no  such  unnatural  method  is  going  to 
solve  the  problem  of  overpopulation,  unless  it  be  at  the  expense  of  the 
destruction  of  the  nation  adopting  it.  Any  nation  that  attempts  by 
limiting  its  birth  rate  to  keep  its  population  stationary  will  just  as  cer- 
tainly fall  behind,  and  later  succumb  to  the  larger  and  more  vigorous 
nations.  To  hold  its  place  in  the  sun,  the  nation,  just  as  the  individual, 
must  have  an  abundance  of  man  power.  A  high  birth  rate  is  to  be 
encouraged  in  every  way,  and  the  size  of  the  family  only  limited 


CONTRACEPTIVES  149 

because  of  definite  congenital  or  acquired  defects.  Immigration  con- 
trol is  preferable  to  birth-control,  but  statesmen  seem  slow  to  read  the 
handwriting  on  the  wall. 

All  of  the  artifices  that  are  used  for  the  prevention  of  conception  or 
the  limitation  of  offspring  are  injurious  alike  to  morals  and  to  physical 
health.  These  are  adopted  only  too  often  by  the  woman  to  deliberately 
evade  the  responsibility  of  maternity.  In  some  cases  they  are  used  as 
measures  of  expediency  so  that  the  woman,  and  she  may  be  a  mother, 
and  often  is,  can  help  earn  the  daily  bread.  It  is  quite  probable  that 
should  such  practices  become  more  general,  more  women  would  engage 
in  those  pursuits  in  which  a  growing  family  impedes  or  limits  her 
activities.  I  should  like  to  quote  at  this  point  Dr.  Goodell,  whose 
words  are  food  for  the  deepest  reflection. 

"The  sexual  instinct  has  been  given  to  man  for  the  perpetuation  of 
his  species;  but,  in  order  to  refine  this  gift  and  to  set  limits  to  its  abuse, 
it  has  been  wisely  ordered  that  a  purely  intellectual  quality — that  of 
love — should  find  its  most  passionate  expression  in  the  gratification  of 
this  instinct.  Dissociate  the  one  from  the  other,  and  man  sinks  below 
the  level  of  the  brute.  Destroy  the  reciprocity  of  the  union,  and  mar- 
riage is  no  longer  an  equal  partnership,  but  a  sensual  usurpation  on  the 
one  side  and  a  loathing  submission  on  the  other ;  wedlock  lapses  into 
licentiousness;  the  wife  is  degraded  into  a  mistress;  love  and  affection 
change  into  aversion  and  hate. 

"Without  suffering  some  penalty  man  cannot  disturb  the  conditions 
of  his  well-being  or  trespass  beyond  its  limitations.  Let  him  traverse 
her  physical  laws  and  Nature  exacts  a  forfeit;  dare  he  violate  his 
moral  obligations,  an  offended  Deity  stands  ready  to  avenge  them, 
Onan  was  slain  for  disobeying  a  divine  command,  by  resorting  to  one 
of  the  'preventive  measures'  still  in  vogue  to-day.  The  husband  suf- 
fers mentally  because  no  man  can  behave  in  so  unmanly  a  way  without 
a  sense  of  remorse.  Further,  he  suffers  physically  as  a  result  of  the 
aborted  or  unnaturally  restricted  orgasm.  Early  exhaustion  and  pre- 
mature decrepitude  result. 

"The  wife  suffers  most  because  she  both  sins  and  Is  sinned  against. 
She  sins  because  she  shirks  those  responsibilities  for  which  she  was 
created.  She  is  sinned  against  because  she  is  defrauded  of  her  rights. 
Lawful  congress  satisfies  an  important  instinct,  and  is  succeeded  by 
calm  repose  of  body  and  mind.  On  the  other  hand,  conjugal  onanism 
provokes  desires  which  are  denied  by  the  nature  of  the  act.  The 
excessive  stimulation  of  the  whole  reproductive  apparatus  remains 


ISO  STERILITY  AND  CONCEPTION 

unappeased.  A  nervous  super-excitation  continues,  which  keeps  up  a 
sexual  excitement  and  hyperesthesia  of  the  parts.  Hence  the  con- 
gestive orgasm  of  the  generative  organs  does  not  at  once  pass  away, 
but  persists  for  some  time.  Thus  arises  engorgement  and  inflamma- 
tions that  lead  to  distorted  views  of  life  and  the  marriage  state. 

"The  very  barrenness  aimed  at  by  these  criminal  expedients  is  in 
itself  a  source  of  disease.  In  sterile  women  the  absence  of  pregnancy 
and  of  suckling  prevents  a  break  in  this  constantly  recurring  cata- 
menia,  and  the  physiological  congestions  of  the  womb  augmented  by 
sexual  congestions  are,  by  ceaseless  repetitions,  liable  to  become  patho- 
logical." 

All  of  the  methods  used  to  prevent  conception  are  borrowed  from 
the  brothel  and,  as  vile  and  disgusting  as  they  are,  they  have  received 
welcome  sanction  in  many  quarters.  They  all  act  in  the  same  way  by 
preventing  the  spermatozoa  from  reaching  the  uterine  cavity,  either 
directly  by  interposing  a  barrier  to  their  passage,  or  indirectly  by 
destroying  them  while  they  are  yet  in  the  vagina.  The  use  of  contra- 
ceptives greatly  affects  the  moral  character  of  both  parties,  not  only 
because  such  unnatural  practices  violate  Nature's  laws,  but  because  the 
absence  of  children  in  the  household  prevents  the  full  development  of 
a  spirit  of  unselfishness  and  sacrifice.  In  this  way  many  miss  the 
inestimable  boon  of  the  renewal  of  youth  through  their  children. 

It  is  not  uncommon  for  medical  men  to  tell  women  who  have 
passed  through  a  difficult  confinement  that  they  should  never  have 
any  more  children,  and  this  irrespective  of  the  fact  that  only  too  often 
such  difficulty  was  the  result  of  a  lack  of  skill  on  their  part  and  that  in 
the  hands  of  one  more  skilled  the  case  would  have  been  a  compara- 
tively simple  one.  This  deters  many  of  the  educated  class  from  frequent 
or  even  successive  child  bearing.  A  certain  amount  of  social  con- 
demnation is  vented  on  the  father  of  a  large  family  if  the  health  of  his 
wife  in  any  way  suffers,  although  her  invalidism  may  not  be  due  in  the 
least  to  the  process  of  parturition. 

The  rich  and  leisure  class  only  too  often  shirk  their  duty  to  the  next 
generation  from  purely  selfish  motives.  When  a  woman  despises  the 
honor  and  responsibilities  of  motherhood  she  commits  a  crime  against 
Nature,  and  in  thus  renouncing  what  has  always  been,  and  must  always 
be,  the  greatest  privilege  and  glory  of  her  sex,  often  lays  up  for  her- 
self undreamed  of  sorrow  in  the  future.  Early  marriage  for  all 
healthy  persons  is  a  duty.  Such  an  ideal  condition  of  society  would 
not  necessitate  the  consideration  of  any  question  of  birth-control. 

It  is  much  to  be  feared  that  undue  familiarity  with  the  laws  of 


CONTRACEPTIVES  151 

physiological  matters  will  lead  to  a  materialistic  view  of  all  sexual 
questions  and  affect  beyond  all  hope  of  redemption  the  morality  of  the 
race.  It  is  quite  easy  to  conceive  how  licentiousness,  protected  by 
methods  of  avoiding  its  consequences,  and  made  respectable  by  cover- 
ing with  a  cloak  of  public  approval,  could  easily  lead  to  an  outbreak 
that  would  be  disastrous  to  the  nation.  To  the  conscience  of  the  indi- 
vidual must  ever  be  left  many  decisions  of  the  married  life.  The 
practice  of  a  certain  degree  of  .self-control  is  ever  excellent  moral 
discipline. 

Metchnikoff  has  called  the  reproductive  instinct  "the  strongest  in- 
stance of  maladaptation  caused  by  civilization."  That  the  sex  instinct 
IS  to-day  far  stronger  than  is  necessary  for  the  perpetuation  of  the 
species,  few  will  deny,  but  this  fact  should  not  be  used  as  an  argument 
for  its  illegitimate  gratification. 

Dr.  Scharlieb  has  very  well  summed  up  the  argument  of  birth- 
control  advocates  as  follows:  "They  opine  that  men  and  women  are 
not  strong  enough  or  wise  enough  to  practice  self-control.  They  seem 
to  be  convinced  that  marriage  is  not  for  the  creation  of  children,  for 
mutual  love  and  support,  nor  for  the  avoidance  of  sin,  but  that  it  is  to 
afford  free  and  legitimate  outlet  for  sex  desires,  to  afford  lifelong 
opportunities  for  unlimited  sex  gratification. 

"Their  arguments  contain  certain  subsidiary  reasons,  as  the  diffi- 
culty of  providing  housing  accommodations ;  the  impossibility  of  pro- 
viding for  more  than  two  or  three  children;  the  injury  inflicted  by 
frequent  child-bearing;  the  difficulty  of  rearing  a  large  family,  and  the 
fear  that  the  world  will  be  unable  to  support  all  the  children  that  may 
be  born.  In  this  connection  it  might  be  pointed  out  that  a  better  answer 
to  all  this  would  be  a  more  equitable  division  of  wealth  and  all  it  stands 
for  than  a  restriction  of  the  population.  It  would  seem  to  most 
thoughtful  students  that  the  philosophy,  if  any,  involved  in  restriction 
of  the  population  is  purely  materialistic  and  that  back  of  it  all  is  the 
desire  to  obtain  gratification  of  the  sex  act  without  incurring  the 
responsibility  that  goes  with  it. 

"Much  good  always  results  from  the  intelligent  regulation  of  the 
human  appetite  whether  for  food,  drink,  or  the  instinctive  desire 
between  the  sexes,  and  it  is  a  well-recognized  fact  among  physicians 
to-day  that  self-control  and  continence  are  not  in  the  least  injurious." 

It  is  generally  accepted  that  all  unnatural  modifications  of  the 
marital  relations  and  all  artificial  methods  aimed  at  the  prevention  of 
conception,  whether  by  chemical  means  or  mechanical  contrivances,  are 
harmful.    The  routine  interference  with  the  spontaneity  of  so  impor- 


152  STERILITY  AND  CONCEPTION 

tant  a  physical  function  as  the  sex  act  has  a  far-reaching  and  dele- 
terious effect  on  the  health  of  those  who  practice  it,  and  if  persisted  in 
eventually  leads  to  unfaithfulness  on  the  part  of  the  husband,  driving 
him  outside  of*his  home  for  those  pleasures  which  it  denies  to  him. 
On  the  part  of  the  woman,  the  habitual  use  of  preventives  early  leads 
to  a  loss  of  beauty,  and  she  becomes  thin  and  neurotic,  a  nuisance  to 
herself  and  to  everyone  else. 

While  scientists,  philosophers,  and  philanthropists  the  world  over 
are  debating  and  deploring  a  declining  birth  rate,  birth-control  is  daily 
performing  its  task.  Among  primitive  peoples,  it  is,  if  not  unknown, 
at  least  unpracticed.  Civilization  has  developed  birth-control  largely 
through  the  efforts  of  those  wishing  frequent  and  often  promiscuous 
intercourse  without  danger  of  incurring  the  responsibilities  of  parent- 
hood. 

The  determining  factors  leading  to  the  adoption  of  methods  of 
preventing  conception  vary  greatly  in  individual  cases,  but  a  false 
system  of  education  will  be  found  responsible  in  the  overwhelming 
majority.  The  wife  is  invariably  the  one  responsible  for  the  family 
restriction.  The  restless  condition  of  our  women  as  developed  by  the 
demands  made  upon  them  by  the  social  vagaries  of  the  day,  their 
expensive  tastes  and  habits  all  have  much  to  do  with  the  desire  for  the 
limitation  of  offspring.  If  to  these  be  added  the  excesses  of  everyday 
life  which  unnaturally  stimulate  the  sexual  apparatus,  we  probably  get 
as  near  as  it  is  possible  to  the  animating  causes  of  this  baneful  practice. 

When  artificial  means  are  used  to  prevent  conception  and  are 
indulged  in  continually  for  any  length  of  time,  they  are  quite  liable  to 
create  a  habit  of  sterility.  Sterility  has  a  special  interest  not  only  for 
the  gynecologist  but  for  all  who  are  interested  in  the  progress  and 
perpetuation  of  the  race,  and  birth-control  spells  disaster  alike  to  the 
marriage  state  and  to  the  home.  It  should  be  opposed  at  every  turn, 
as  it  is  subversive  to  the  best  interests  of  society,  and  if  put  into  effect 
would  destroy  all  that  God  and  man  have  built  up  in  past  generations. 
Practiced  clandestinely,  it  is  one  of  the  greatest  enemies  of  the  race 
to-day,  and  if  legalized,  would  in  a  short  time  sweep  us  from  the  face 
of  the  earth. 

LITERATURE 

GOODELL.     loc.  Cit. 

Sanger,  Margaret.    Woman  and  the  New  Race.     1920. 
ScHARUEB.    Report,  British  Birth  Rate  Commission.     192 1. 


CHAPTER   XXI 

ABORTION,  PREMATURE  BIRTH,  AND  FETICIDE 

Legal  definition  of  abortion — Criminal  abortion — Relative  frequency  of  interrupted 
pregnancy — Hospital  statistics  of  antenatal  death — Toxemias  of  pregnancy — 
Prematurity — Infections — Gonorrhea — Hemorrhage — Percentage  of  prematurity 
— Case  report — Accidents  of  childbirth. 

By  common  law  the  fetus  in  utero  is  not  entitled  to  any  legal  pro- 
tections or  particular  consideration  until,  after  quickening  has  taken 
place,  and  its  destruction  at  any  time  before  quickening  is  not  looked 
upon  as  a  crime.  With  the  appearance  of  quickening,  life  is  supposed 
to  begin,  and  thereafter  the  destruction  of  the  fetus  by  its  host,  the 
mother,  or  by  a  third  party  constitutes  only  a  misdemeanor  and  is  not 
a  crime  which  can  be  punished  by  imprisonment.  In  some  state 
statutes  which  take  the  place  of  the  common  law,  there  is  no  distinction 
made  between  the  animate  and  inanimate  fetus ;  the  induction  of  abor- 
tion being  punishable  by  imprisonment  for  varying  lengths  of  time. 
The  intent  to  induce  an  abortion  constitutes  the  crime,  which  is  not 
dependent  in  any  way  upon  the  consent  of  the  mother  or  the  success 
of  the  method  employed.  When  the  mother  dies,  the  act  then  becomes 
murder. 

Notwithstanding  the  wide  prevalance  of  criminal  abortion  to-day, 
there  are  very  few  accusations  or  indictments  unless  the  mother's  con- 
dition becomes  serious,  or  she  dies.  One  of  the  great  stumbling  blocks 
to  the  proper  punishment  of  the  criminal  abortionist  is  the  old 
common-law  interpretation  which  does  not  recognize  the  presence  of 
life  on  the  part  of  the  fetus  until  quickening  has  occurred,  for  this  is 
still  the  current  belief  of  a  large  proportion  of  our  population  to-day. 

Life  is  present  from  the  time  conception  first  occurs,  otherwise 
there  could  be  no  growth  of  the  fetus,  and  it  is  the  woeful  ignorance 
of  this  physiological  fact  that  does  so  much  to  keep  alive  the  crime  of 
feticide.  When  the  embryo  or  fetus  is  destroyed,  there  is  an  injury 
to  the  prospective  individual,  for  the  fetus  is  a  living,  independent 
being,  has  the  right  to  exist  which  is  common  to  all  human  beings,  and 

153 


154  STERILITY  AND  CONCEPTION 

is  entitled  to  protection  from  the  State.  By  the  induction  of  abortion 
a  direct  injury  is  done  to  the  mother,  for  the  operation  subjects  her  to 
an  unjustifiable  risk  both  to  her  life  and  to  her  health.  It  is  likewise 
an  injury  to  the  relatives  of  the  unborn  child,  and  is  also  an  injury  to 
the  State  by  depriving  it  of  a  prospective  citizen.  The  direct  taking 
of  an  innocent  human  life  is  always  murder.  The  crime  is  just  as 
great  at  whatever  stage  of  existence  it  is  committed.  Every  "success- 
ful" abortion  results  in  at  least  one  murder,  that  of  the  unborn  child, 
and  in  every  "unsuccessful"  abortion  there  are  usually  two  murders, 
that  of  the  unborn  child  and  that  of  the  prospective  mother  as  well. 

Criminal  Abortion. — Criminal  abortion,  in  its  many  phases,  is 
more  common  to  the  married  state,  and  most  of  these  cases  are  in 
women  who  desire  the  removal  of  the  pregnancy  for  purely  selfish 
reasons  rather  than  to  save  delicate  and  compromising  situations. 
Although  there  are  many  who  ask  for  relief  on  the  ground  of 
poverty  and  too  frequent  child-bearing;  yet  the  majority  state 
that  they  have  no  time  to  devote  to  maternal  cares.  The  attitude 
of  the  educated  conscientious  physician  is  hostile  to  abortion 
except  for  therapeutic  reasons,  but  there  is  a  large  and  constantly 
increasing  number  of  physicians  who  are  willing  to  constitute 
themselves  both  judge  and  executioner.  Nearly  all  of  the  desper- 
ate and  fatal  cases  of  abortion  occur  in  its  criminal  practice ;  the 
most  frequent  cause  of  death  being  perforation  of  the  uterus, 
peritonitis,  and  septicemia. 

Abortion  is  an  important  factor  in  relative  sterility  and  is  of 
very  frequent  occurrence.  It  is  impossible  to  estimate  at  anything 
like  its  true  percentage  the  role  it  plays  in  the  causation  of  sterility 
and  as  a  factor  in  the  production  of  lessened  fertility,  but  its  effect 
in  lowering  the  birth  rate  is  appalling  and  difficult  to  even  con- 
template without  a  shudder.  While  it  is  quite  true  that  spon- 
taneous abortion  is  of  very  frequent  occurrence,  having  been 
estimated  as  taking  place  about  once  in  every  six  pregnancies,  a 
larger  number  of  abortions  are  intentional,  premeditated  and 
induced  without  the  slightest  therapeutic  or  possible  social  justi- 
fication. 

Medical  science,  by  improved  methods  of  treatment,  has  been 
able  to  accomplish  much  in  the  prevention  of  spontaneous  abor- 
tion, but  social  science  has  been  powerless  to  check  the  advance 
of  criminal  abortion,  and  feticide  to-day,  which  has  reached  such 
enormous  proportions,  constitutes  a  very  real  menace  to  the  race. 


,  ABORTION,  PREMATURE  BIRTH,  AND  FETICIDE  155 

Comparatively  few  pregnancies  are  really  interrupted  by  the 
woman  herself,  considering  the  frequency  with  which  this  is 
attempted,  or  by  that  casual  offender,  "the  kind  hearted  physician" 
anxious  to  relieve  distressed  womanhood.  The  great  majority  of 
inductions  are  the  work  of  the  professional  operator,  who  abounds 
in  all  large  centers  of  civilization.  His  advertisements  appear 
regularly  in  the  daily  press  and  his  "professional  cards"  are  dis- 
tributed broadcast  in  the  community.  I  have  known  of  many 
apartment  houses  where  each  incoming  family  was  supplied  by 
the  janitress,  his  stool  pigeon,  with  his  cards  in  common  with 
those  of  the  best  neighborhood  butcher,  baker,  and  candle-stick 
maker. 

This  notorious  offender  against  society  has  so  successfully 
developed  his  vocation  that  criminal  abortion  is  frequently  spoken 
of  in  foreign  medical  circles  as  "the  American  specialty,"  This  is 
the  man  with  morals  beneath  contempt  or  pity,  whose  daily  life 
it  is  a  very  shame  to  mention,  and  with  whom  they  would  no  more 
think  of  associating  than  with  a  leper,  that  countless  thousands  of 
our  women  go  to  every  year  to  be  relieved  of  the  burdens  of 
maternity  so  that  they  may  have  more  time  and  means  to  indulge 
in  purely  selfish  pleasures.  Some  never  return,  for  his  mortality 
is  high,  many  come  back  to  a  life  of  chronic  invalidism ;  all  are 
injured  morally.  Is  there  not  manhood  enough  in  public  life,  or 
power  enough  in  the  courts,  or  virtue  enough  in  the  criminal  code 
to  give  this  odious  creature  his  deserts?  It  would  seem  not,  for 
he  still  thrives  almost  undisturbed. 

Chandler,  from  exhaustive  study,  has  stated  it  as  his  firm  con- 
viction that  more  than  one-half  of  the  human  race  dies  before 
birth  and  that  three-fourths  of  all  these  are  deliberately  destroyed. 

Abortion  is  the  ending  of  pregnancy  within  the  first  three 
months  before  the  placenta  is  formed.  After  this  and  up  to  the 
period  of  viability,  at  about  seven  months,  the  term  miscarriage 
is  used.  When  the  child  is  viable,  yet  born  before  term,  it  is 
spoken  of  as  premature,  and  if  born  dead,  as  stillborn.  Abortion 
occurs  with  greater  frequency  than  does  miscarriage. 

Relative  Frequency  of  Interrupted  Pregnancy. — The  causes  of 
interrupted  pregnancy  are  varied,  and  there  seems  but  little  unanimity 
of  opinion  regarding  their  relative  frequency.  When  a  woman 
has  aborted  more  than  once  for  no  assignable  cause,  a  careful 
inquiry  into  her  history   should  be   instituted   and   a   thorough 


156  STERILITY  AND   CONCEPTION 

physical  examination  made  with  the  object  of  determining  the 
cause  and  carrying  out  the  proper  treatment  to  avoid  a  similar 
occurrence  with  the  next  pregnancy.  Subinvolution  of  the  uterus 
and  chronic  endometritis  are  best  treated  by  tampons  of  ichthyol 
and  glycerine  and  with  the  curette.  Displacements  of  the  uterus 
should  be  corrected  and  the  uterus  supported  by  a  pessary  or, 
failing  in  this,  operative  measures  should  be  carried  out.  Ex- 
tensive laceration  of  the  cervix,  a  frequent  cause  of  abortion, 
should  be  repaired.  Syphilis  and  toxemia  call  for  their  appro- 
priate treatment. 

A  study  of  hospital  statistics  shows  that  far  more  than  one- 
half  of  all  antenatal  deaths  are  due  either  to  syphilis,  which  is 
responsible  for  about  twenty  per  cent,  or  maternal  toxemia,  which 
accounts  for  about  ten  per  cent.  Twenty-five  per  cent  to  forty 
per  cent  are  attributable  to  accidents  and  complications  occurring 
during  labor,  while  prematurity,  malnutrition,  fetal  deformities, 
alcohol,  and  criminal  abortion  enact  their  toll. 

It  has  been  demonstrated  by  recent  investigation  that  the 
unborn  child  can  be  safely  treated  by  salvarsan  through  its  mother 
during  the  period  of  its  intra-uterine  growth.  It  is  quite  prob- 
able that  in  syphilis,  the  placenta  and  its  little-understood  fer- 
ments exercise  for  a  while  a  certain  inhibitory  action  upon  the 
infecting  organism  and  thus  affords  time  for  treatment  to  be 
instituted,  even  though  it  is  not  begun  until  the  pregnancy  is  well 
advanced. 

Toxemia  of  Pregnancy. — Toxemia  of  pregnancy  frequently 
causes  the  death  of  the  child.  This  is  brought  about  by  some 
unknown  chemical  poison,  the  method  of  production  of  which  is 
unknown.  When  the  toxemia  is  of  gradual  onset  and  is  detected 
early,  active  treatment  will  often  be  successful  in  saving  the  life  of 
both  mother  and  child,  but  in  the  virulent  type  of  toxemia,  with 
sudden  onset,  a  specific  treatment  has  not  yet  been  discovered, 
and  these  cases  are  practically  hopeless. 

The  greatest  single  group  of  causes  of  antenatal  and  natal 
death  is  probably  that  of  the  accidents  and  complications  of  labor, 
which  are  responsible  for  something  like  twenty-five  per  cent  of 
disaster.  Most  of  these,  classed  as  pelvic  contraction,  tumors,  and 
grave  fetal  displacement,  are  diagnosable  before  labor  begins,  so 
that  appropriate  manipulative  or  surgical  treatment  can  often  be 


ABORTION,   PREMATURE   BIRTH,  AND   FETICIDE  157 

instituted  in  time  to  correct  the  abnormality.    The  mortahty  rate 
due  to  these  causes  should  be  greatly  reduced. 

Much  worthy  endeavor  to  secure  adequate  medical  supervision 
of  expectant  mothers,  by  the  establishment  of  maternity  centers, 
antenatal  clinics,  and  by  seeing  that  complicated  cases  gain  timely 
admission  to  the  hospital,  has  been  productive  of  great  benefit, 
but  much  remains  to  be  accomphshed  along  these  lines  as  well  as 
in  giving  to  midwives  and  doctors  a  more  practical  education  in 
obstetrics. 

The  causes  of  antenatal  death  are  varied.  Malnutrition, 
anemia,  etc.,  exert  a  strong  influence,  while  acute  specific  and 
infectious  diseases,  such  as  small-pox,  scarlatina,  measles,  enteric 
fever,  influenza,  erysipelas,  pyelitis,  and  pneumonia,  are  all  more 
or  less  frequent  etiological  factors.  The  chronic  diseases,  such  as 
tuberculosis,  syphilis,  diabetes,  Bright's  disease,  and  serious  car- 
diac disturbances,  produce  many  antenatal  deaths.  The  tropical 
diseases,  so-called,  malaria,  cholera,  and  dysentery,  may  at  times 
have  to  be  considered  in  this  respect,  and  the  toxemias,  pernicious 
vomiting,  albuminuria,  eclampsia,  and  acute  yellow  atrophy  of  the 
liver,  cause  many  an  intra-uterine  death. 

Again,  antenatal  death  may  be  due  to  purely  mechanical  meas- 
ures, as  occurs  in  retroversion  of  the  gravid  uterus,  pelvic  contrac- 
tion, obstructing  tumors,  such  as  fibro-myomata  of  the  uterus  and 
growths  of  the  ovary,  carcinoma  of  the  cervix,  cicatricial  stenosis 
of  the  cervix,  vagina,  etc.,  undue  ventrifixation  of  the  uterus,  and 
vulvar  abnormalities. 

Under  miscellaneous  causes  of  antenatal  death  may  be  men- 
tioned pelvic  inflammation,  antepartum  hemorrhage  due  to  either 
placenta  previa,  or  accidental  separation  of  the  placenta,  ectopic 
pregnancy,  criminal  abortion,  and  operations  during  pregnancy. 

On  the  part  of  the  fetus  itself,  conditions  may  develop  which 
result  in  antenatal  death,  such  as  hydramnios,  or  pathological 
changes  developing  in  the  chorion,  blood  vessels  of  the  endo- 
metrium, or  the  presence  of  a  uterine  mole. 

Mechanical  factors  on  the  part  of  the  fetus  are  malposition  and 
malpresentation,  malformation,  and  a  relatively  large  child. 

Prematurity. — Prematurity  is  largely  the  result  of  conditions 
which  cause  ill  health  of  the  child  and  early  delivery.  It  has  been 
estimated  that  about  sixty  per  cent  of  all  children  born  prematurely 
die  within  the  first  twenty-four  hours,-  and  these  constitute  about  ten 


iS8  STERILITY  AND  CONCEPTION 

per  cent  of  all  antenatal  deaths.  While  pneumonia  as  a  germ  disease 
does  not  in  itself  infect  the  child,  it  may  yet  cause  its  death  by  dyspnea, 
the  result  of  absorption  of  toxic  products  from  its  mother's  blood. 

Gonorrhea. — The  effect  of  gonorrhea  is  usually  only  local,  and  it 
cannot  be  considered  as  an  important  factor  in  the  causation  of  abor- 
tion, except  in  the  presence  of  an  acute  attack  in  the  very  early  weeks 
of  pregnancy. 

Hemorrhage. — Accidental  hemorrhage,  generally  due  to  pre- 
mature separation  of  the  placenta,  always  causes  fetal  death  and  very 
often  kills  the  mother  as  well. 

Bleeding  from  the  uterus  in  the  early  months  of  pregnancy  may 
be  due  to  various  causes  and  is  not  at  all  uncommon.  In  many  of 
these  cases  the  bleeding  eventually  subsides  without  causing  the  death 
of  the  fetus,  but  in  a  certain  number  the  pregnancy  terminates  as  a 
direct  result  of  interference  with  its  nutrition. 

Apoplexy  of  the  placenta  may  cause  antepartum  hemorrhage  and 
a  stillborn  child. 

Percentage  of  Prematurity. — There  has  come  from  the  Uni- 
versity of  California  Hospital  a  very  interesting  report  by 
McQuarrie,  based  upon  a  series  of  2717  deliveries  Reckoning 
from  the  period  of  possible  viability  at  the  thirtieth  week  to 
twelve  hours  after  delivery,  he  found  that  there  were  ninety-seven 
fetal  deaths,  which  gave  a  fetal  mortality  of  3.6  per  cent.  There  were 
twenty-two  cases  of  fetal  death  occurring  before  the  age  of  viability 
during  the  fifth  and  sixth  months,  which  brought  the  total  deaths 
up  to  119,  a  percentage  of  4.4.  In  his  report  he  makes  the  fol- 
lowing tabulation : 

CAUSES  AND  PERIODS  OF  FETAL  DEATHS 

Cause                             Under  30  Weeks     Over  30  Weeks     Percentage 

Syphilis .0  15  15.5 

Unknown   5  17  17.5 

Birth  trauma o  36  37.1 

Toxemia 4  9  9^2 

Fetal  abnormality  i  8  8.2 

Prematurity    2  5  5.3 

Placenta  previa 2  2  2.0 

Various    8  5  5.2 

22  97  1 00.0 

In  the  group  of  cases  where  syphilis  was  a  cause,  there  were 
fifteen  cases  in  all.    The  diagnosis  was  made  in  every  instance  by 


ABORTION.  PREMATURE  BIRTH,  AND  FETICIDE  159 

a  Wassermann  test,  and  all  of  the  mothers  had  antisyphilitic  treat- 
ment during  pregnancy. 

Cases  where  the  cause  of  death  was  put  down  as  "Unknown" 
numbered  seventeen,  and  of  these  ten  of  the  infants  were  born 
macerated.  Sufficient  evidence  could  not  be  found  at  necropsy 
to  make  a  definite  diagnosis  of  syphilis,  although  it  was  considered 
that  about  eighty  per  cent  of  these  cases  were  in  reality  syphilitic. 

Premature  birth  is  of  fairly  frequent  occurrence,  but  there  is  a 
wide  variation  in  published  reports  on  this  point.  For  instance, 
the  Rotunda  Hospital  gives  only  one  to  two  per  cent,  while  the 
Vienna  Clinic  places  it  at  thirty-five  per  cent,  and  the  Paris 
Maternity  returns  twenty  per  cent.  When  we  come  to  a  study  of 
the  mortality  rate  in  premature  children  we  will  find  the  important 
fact  quite  evident — that  prematurity  is  a  common  cause  of  still- 
birth and  infantile  death,  and  as  such  has  a  more  or  less  direct 
bearing  on  sterility.  The  nearer  the  labor  to  term,  the  better  the 
prospect  for  the  child.  The  more  frequent  causes  of  premature 
birth  are  antepartum  hemorrhage,  toxemia,  undue  physical  effort 
or  mental  strain  on  the  mother's  part,  or  malnutrition  or  morbid- 
ity of  the  child. 

Every  once  in  a  while  a  case  will  be  met  with  where  for  no 
discoverable  cause  the  woman  repeatedly  starts  labor  pre- 
maturely, and  the  baby  is  either  stillborn  or  dies  shortly  after 
birth,  yet  without  any  pathology  to  account  for  its  death.  The 
appropriate  treatment  for  such  cases  is  to  stave  off  the  premature 
onset  of  labor  and  carry  the  woman  tc  term.  When  this  can  be 
accomplished  the  child  usually  survives.  The  following  case  is 
illustrative  of  this  curious  phenomenon : 

Mrs.  E.  S.,  twenty-seven  years  of  age,  married  six  years,  during  which  time  she 
had  given  birth  to  four  children.  The  first  child,  weighing  nine  pounds,  born 
spontaneously  at  term  after  a  five-hour  labor,  is  alive  and  well.  With  the  second 
pregnancy,  labor  began  from  two  to  three  weeks  early  and  terminated  after  two 
hours  in  the  birth  of  a  baby  which  appeared  healthy  but  lived  only  one  hour.  With  the 
third  pregnancy  labor  started  three  weeks  early,  lasted  nine  hours  and  terminated  in 
the  birth  of  an  apparently  healthy  child  which  lived  only  one  hour.  With  the 
fourth  pregnancy,  labor  again  started  two  weeks  early,  lasting  nine  hours,  and  a 
healthy  nine-pound  baby  was  born.  This  also  died  at  the  end  of  an  hour.  No 
cause  for  death  could  be  found  with  any  of  these  children.  The  mother  and 
father  were  both  in  perfect  health. 

I  saw  the  patient  for  the  first  time  with  her  fifth  pregnancy  when  she  was  in 
her  seventh  month,  and  had  her  under  constant  observation  from  that  time  on,  her 
condition  remaining  perfectly  normal.     Two  weeks  before  her  expected  date  of 


i6o  STERILITY  AND  CONCEPTION 

labor,  she  began  to  have  strong  uterine  contractions  coming  on  regularly  every 
fifteen  to  twenty  minutes.  Opium  was  administered  to  the  point  where  the  con- 
tractions were  lessened,  and  at  the  end  of  twelve  hours  they  ceased  entirely.  The 
cervix,  which  had  dilated  up  to  two  fingers,  closed  down  again  to  one  finger.  One 
week  after  this  the  same  symptoms  appeared,  contractions  being  strong  and  regular. 
The  cervix  this  time  dilated  to  three  fingers.  The  pains  were  again  controlled  by 
opium,  as  in  the  first  instance,  and  finally  subsided,  the  cervix  contracting  down  to 
one  finger.  One  week  later  labor  again  started  and  was  allowed  to  progress  with- 
out interference.  At  the  end  of  three  hours  a  normal  eight-pound  ten-ounce, 
healthy  living  child  was  born. 

The  frequency  with  which  still-births  or  the  birth  of  children 
who  live  only  a  short  time  thereafter  still  takes  place  calls  loudly 
for  better  medical  care  of  the  mother  before  as  well  as  during  her 
confinement.  It  is  not  fair  to  her  that  she  should  be  called  upon 
to  undergo  all  the  trials  and  dangers  incident  to  pregnancy  and 
child  bearing  only  to  lose  her  baby  before  or  shortly  after  it  is 
born.  The  great  value  of  antenatal  treatment  cannot  be  over- 
estimated. 

Accidents  of  Childbirth. — A  certain  number  of  fetal  deaths,  the 
result  of  accident,  cannot  be  avoided,  such  as  are  those  due  to 
apoplexy  of  the  placenta,  knotting  of  the  cord,  breech  presenta- 
tion, premature  rupture  of  the  membranes,  and  various  injuries  to 
the  mother.  Extremes  of  youth  or  old  age  in  the  parents  and 
chronic  diseases  are  predisposing  causes.  While  syphilis  is  the 
cause  of  a  large  proportion  of  stillbirths,  it  is  a  preventable  one  in 
many.  I  do  not  believe  that  it  should  be  held  responsible  for  the 
overwhelming  majority.  It  is  time  that  a  fair  share  of  the  blame 
was  placed  where  it  belongs — on  the  shoulders  of  incompetent 
obstetrics.  Until  this  is  done  and  we  demand  for  our  women  the 
same  amount  of  surgical  skill  at  obstetrical  operations  as  is 
accorded  them  at  other  major  surgical  operations,  the  great  num- 
ber of  children  who  die  before  they  ever  see  the  light  of  day,  or 
shortly  thereafter,  will  still  continue  to  disgrace  the  annals  of 
medicine. 

LITERATURE 

Edgar,  J.  C.    Practice  of  Obstetrics.    1903. 
McQuARRiES.    Journ.  Am.  Med.  Assn.     1919. 
RucKER,  M.  P.     So.  Med.  Journ.     192 1. 
Shears,  G.  P.    Obstetrics.     192 1. 
Williams,  J.  W.    Obstetrics.    1903. 


CHAPTER   XXII 

PESSARY  TREATMENT  OF  RETRODISPLACEMENTS  IN  STERILITY 
Postpartum  retrodisplacement — Technique — Types  of  pessary — Function  of  pessary. 

With  the  rapid  development  of  gynecological  surgery  during 
the  past  decade  or  so  the  pessary  treatment  of  displacements  has 
been  to  a  great  extent  laid  aside  and  by  many  entirely  forgotten. 
It  is  unfortunate  that  such  should  have  been  the  case,  because  the 
pessary  is  of  great  value.  It  is  not  my  purpose  in  this  chapter  to 
discuss  at  any  considerable  length  the  various  uses  of  the  pessary, 
but  only  to  take  up  briefly  its  use  in  cases  of  retrodisplacement 
affecting  the  fecundity  of  the  patient.  In  postpartum  retrodis- 
placement, we  find  its  field  of  greatest  usefulness,  and  there  are 
very  few  of  these  cases  which  cannot  be  cured  by  its  proper  use. 
Whereas  the  proper  fitting  of  a  pessary  in  a  difficult  case  requires 
considerable  experience  and  practice,  its  introduction  in  the  great 
majority  of  cases  is  comparatively  simple.  The  pessary,  when 
properly  fitted,  often  effects  a  cure;  when  improperly  fitted,  never 
effects  a  cure.  Before  any  attempt  is  made  to  introduce  the  pes- 
sary the  uterus  should  be  replaced  and  the  presence  of  adnexal 
disease  ruled  out.  Such  involvement  is  usually  a  contra-indication 
to  the  use  of  the  pessary.  Of  the  various  means  of  effecting 
replacement  of  the  uterus,  some  are  applicable  to  certain  cases 
which  would  be  useless  in  others. 

Postpartum  Retrodisplacement. — When  the  displacement  is  a 
postpartum  one,  diagnosed  shortly  after  delivery,  much  may  be 
accomplished  by  postural  treatment,  that  is,  by  having  the  patient 
assume  the  knee-chest  position  for  fifteen  minutes  several  times  a 
day;  whenever  lying  down,  an  extreme  Sims,  or  face  position, 
should  be  taken.  It  is  a  great  mistake  to  allow  these  cases  to  lie 
on  their  backs.  The  advice  often  given  to  cases  of  threatened 
abortion  to  go  to  bed  and  lie  flat  on  their  back  until  the  symptoms 
subside  is  most  pernicious,  for  in  many  of  these  the  threatened 

i6i 


i62-  STERILITY  AND  CONCEPTION 

abortion  is  due  to  a  retrodisplacement  which  the  dorsal  position 
only  helps  to  maintain  and  increase.  "He  who  cures  a  disease 
may  be  the  skillfulest,  but  he  who  prevents  it  is  the  safest 
physician,"  says  the  old  proverb. 

When  the  knee-chest  position  is  prescribed,  the  patient  should 
be  shown  how  to  separate  the  labia  widely  to  allow  the  air  to  enter 
and  distend  the  vagina.  This  is  an  important  adjunct  in  helping 
to  gravitate  the  fundus  forward.  In  a  vagina  thus  ballooned  out 
by  the  in-rushing  air,  the  anterior  vaginal  wall  draws  on  the  cervix 
and  the  distention  of  the  cul-de-sac  dislodges  the  fundus,  which 
then  drops  forward  into  position.  As  the  fundus  is  yet  large  and 
soft,  the  angle  of  flexion  at  the  cervix  straightens  out  and  the 
fundus  swings  forward  into  normal  anteversion.  The  patient  can 
then  lower  herself,  lying  on  her  face,  and  should  maintain  for 
some  time  this  face  position,  relieved  occasionally  by  the  extreme 


Fig.  1 8. — Author's  Uterine  Repositor. 

lateral  or  Sims  position.  These  are  the  only  two  reclining  posi- 
tions she  should  ever  thereafter  assume  in  bed.  If  this  simple 
procedure  is  not  sufficient  to  dislodge  the  retroflexed  fundus, 
then  with  the  patient  in  the  knee-chest  position  the  physician 
passes  the  index  finger  high  up  in  the  cul-de-sac  and  dislodges  the 
fundus  from  the  hollow  of  the  sacrum.  If  this  should  be  unsuc- 
cessful, through  inability  to  reach  high  enough  with  the  finger, 
a  sponge  holder  or  dressing  forceps  armed  with  a  small  ball  of 
cotton  may  be  used  as  a  lever.  Any  great  degree  of  force  during 
this  procedure  is  unnecessary  and  should  never  be  attempted. 
In  conjunction  with  the  above  method,  traction  on  the  anterior 
lip  of  the  cervix  by  means  of  a  tenaculum  forceps  is  often  of  help. 
If  the  patient  is  an  ambulatory  one,  or  is  ready  to  get  out  of  bed, 
then  it  is  wiser  to  introduce  a  pessary  while  she  is  still  in  the  knee- 
chest  position,  allowing  her  then  to  turn  over  on  her  back  for  a 
re-examination  to  make  sure  the  fundus  is  held  in  place.  When 
the  uterus  has  been  replaced  and  a  proper  pessary  fitted,  there  is 


PESSARY   TREATMENT  OF   RETRODISPLACEMENTS  163 

little  chance  of  a  recurrence  so  long  as  the  pessary  is  worn.  In 
cases  where  the  displacement  existed  before  the  pregnancy  or 
followed  a  previous  delivery,  the  pessary  should  be  introduced  as 
a  prophylactic  measure,  even  though  the  uterus  is  found  in  normal 
position.  If  the  postural  treatment  carried  out  in  this  way,  assisted 
by  the  manipulations  above  described,  is  n©t  sufficient  to  enable 
one  to  effect  a  reposition,  then  recourse  should  be  had  to  the 
bimanual  method  of  replacement.  This  method  is  of  value  in 
those  cases  where  the  displacement  has  existed  for  some  length 
of  time  and  the  uterus  is  small,  in  other  words,  the  chronic  retro- 
displacements.  The  technic  of  this  method  of  reduction  is  as 
follows. 

Technic. — The  patient  is  placed  in  the  dorsal  position,  pref- 
erably upon  an  examining  table  rather  than  a  bed.  The  vagina 
is  then  opened  with  a  Sims  speculum,  the  anterior  vaginal  wall 
elevated  in  order  to  disclose  the  cervix,  and  its  anterior  lip 
then  grasped  and  drawn  down.  In  replacing  many  retroversions 
and  retroflexions,  downward  traction  on  the  cervix  and  its  satis- 
factory control  throughout  the  manipulation  are  of  the  utmost 
importance.  For  this  purpose  the  ordinary  traction  forceps  gen- 
erally used,  though  in  most  cases  a  very  efficient  instrument,  is, 
nevertheless,  lacking  in  some  important  respects.  These  I  have 
endeavored  to  supply  in  the  repositor  shown  on  page  162.  This 
has  helped  me  very  materially  in  this  work,  and  in  difficult  cases 
has  many  times  proved  itself  invaluable. 

The  Sims  speculum  is  now  withdrawn  and  moderate  traction 
made  on  the  cervix  in  the  line  of  axis  of  the  vagina.  This  should 
not  be  sufficiently  strong  to  cause  the  patient  any  pain,  and  should 
be  persisted  in  for  a  few  moments,  when  the  uterine  supports  will 
gradually  relax,  enabling  the  cervix  to  be  drawn  well  down  to  the 
vaginal  outlet.  This  procedure  is  of  value  in  helping  to  straighten 
out  the  angle  of  flexion  and  will  often  convert  a  retroflexion  into 
a  retroversion.  The  index  finger  of  the  disengaged  hand  is  now 
introduced  high  up  in  the  cul-de-sac,  or  better  yet  in  the  rectum, 
so  that  its  terminal  digit,  slightly  flexed,  lies  behind  the  uterus  a 
little  above  the  internal  os,  against  which  it  presses,  acting  as  a 
fulcrum.  By  means  of  this  repositor  the  cervix  is  now  pushed 
backwards  and  upwards  into  the  hollow  of  the  sacrum,  when  the 
fundus  will  usually  swing  forward  into  an  anterior  position.  In 
executing  this  maneuver,  the  button  on  the  anterior  jaw  of  the 


Fig.  19.— Manual  Replacement  of  Retroflexed  Uterus,     i,  first  step,    2,  second 

step.     3,  final  step. 

164 


PESSARY  TREATMENT  OF  RETRODISPLACEMENTS  165 

repositor  impinges  against  the  anterior  cervical  lip,  preventing 
the  arm  of  the  instrument  from  pushing  through  the  cervix,  often 
a  troublesome  happening  when  an  ordinary  pair  of  tenaculum 
forceps  is  used.  The  thumb  belonging  to  the  hand  whose  index 
linger  has  been  used  as  a  fulcrum  is  then  pass'vid  through  the  ring 
on  the  repositor  attached  to  its  under  arm,  and  holds  both  cervix 
and  repositor  in  position,  thus  releasing  the  other  hand  to  be  used 
on  the  abdomen  when  necessary  in  assisting  the  fundus  forward. 
After  the  replacement  has  been  accomplished,  the  vaginal  finger, 
in  conjunction  with,  the  abdominal  hand  placed  over  the  fundus, 
by  more  or  less  considerable  pressure,  bends  the  cervix  and  fundus 
together,  thus  producing  a  marked  anteflexion,  which  later 
recedes  to  a  normal  anteversion.  Occasionally  in  extreme  retro- 
flexion it  will  be  found  that  the  fundus  has  passed  between  the 
utero-sacral  ligaments  which,  closing  over  it  anteriorly,  interfere 


c> 


Pig.  20. — Smith  Retroflexion  Pessary. 

with  or  may  prevent  its  replacement  by  the  above  method.  In 
such  cases  the  rectal  finger  presses  against  one  of  the  uterosacral 
ligaments,  pushing  it  far  enough  to  the  side  to  release  the  fundus, 
or  release  may  be  effected  by  manipulations  with  the  abdominal 
hand  alone,  when  the  wall  is  thin  and  relaxed.  Now  with  the 
abdominal  hand  placed  over  and  back  of  the  fundus,  the  uterus  is 
held  firmly  forward  against  the  symphysis,  while  the  free  hand 
releases  the  repositor  and  inserts  the  pessary. 

The  success  of  this  method  just  outlined  above  depends  upon 
more  or  less  extreme  relaxation  of  the  abdominal  wall,  secured  by 
an  intelligent  cooperation  on  the  part  of  the  patient  or,  when 
necessary,  by  the  administration  of  an  anesthetic.  Without  an 
anesthetic  great  gentleness  is  necessary  throughout,  for  if  the 
patient  is  hurt  her  cooperation  is  usually  lost  and  the  reposition 
becomes  difficult  or  impossible.  The  choice  of  the  pessary  to  be 
used  depends  upon  the  individual  requirements  of  the  case.  The 
size  of  the  vagina,  its  length,  and  breadth  should  be  carefully 
taken  into  consideration  when  making  a  selection.  A  large,  sub- 
involuted  vagina  will  require  a  large  pessary  at  first,  which  later 


i66  STERILITY  AND  CONCEPTION 

can  be  replaced  by  a  smaller  one.  In  recent  postpartum  displace- 
ments the  first  pessary  used  should  be  considerably  larger  than 
the  one  which  will  ultimately  be  used  a  few  weeks  later. 

Types  of  Pessary. — As  involution  progresses  pessaries  of  a 
smaller  size  can  be  progressively  substituted.  A  short,  broad 
vagina  requires  a  short,  broad  pessary,  whereas  a  long,  narrow 
vagina  requires  one  of  corresponding  length  and  narrowness.  If 
a  pessary  long  enough  for  the  case  is  not  broad  enough  to  stay  in 
place,  then  a  size  larger  pessary  may  be  shortened  by  immersing 
in  boiling  water  for  a  few  moments  and  when  it  has  softened 
sufHciently,  pressing  the  ends  together.  Likewise  when  the  pes- 
sary is  too  broad,  but  not  sufficiently  long,  it  can  be  made  suitable 
by  pressing  the  sides  together  instead  of  the  ends.  These  are 
about  the  only  changes  that  need  to  be  made  in  the  stock  pes- 
saries, and  they  are  not  often  found  necessary. 

The  Albert  Smith  retroversion  pessary  I  prefer  to  all  others. 
Sizes  from  three  and  a  half  inches  in  length  up  will  be  found  the 
most  suitable.  Having  selected  the  pessary  that  seems  most  likely 
to  suit  the  case,  the  index  finger  is  introduced  into  the  vagina  and 
retracts  the  perineum.  The  larger  end  of  the  pessary  is  then 
introduced  first.  It  should  be  borne  in  mind  in  introducing  the 
pessary  that  the  diameter  of  the  introitus  is  vertical  or  antero- 
posterior, so  that  as  the  pessary  passes  over  the  perineum  it  must 
lie  on  its  side.  The  vagina,  however,  is  normally  a  collapsed  tube 
with  its  largest  diameter  transverse,  and,  therefore,  as  the  pessary 
enters  the  vagina  it  must  rotate,  so  as  to  eventually  lie  with  its 
lateral  or  transverse  diameter  corresponding  to  the  transverse 
diameter  of  the  vagina.  After  the  pessary  is  introduced  at  the 
outlet,  and  when  about  one-half  of  it  has  passed  over  the  peri- 
neum, it  will  then  act  as  its  own  perineal  retractor,  and  the  finger 
which  has  been  used  for  this  purpose  can  be  released  and  passed 
upwards  until  it  rests  against  the  concave  bend  of  the  greater  bow. 
Upward  and  backward  pressure  with  the  index  finger  at  this  point 
on  the  pessary  and  in  the  direction  of  the  cul-de-sac  carries  the 
larger  end  of  the  pessary  directly  backwards  into  the  hollow  of 
the  sacrum  behind  the  cervix.  When  this  maneuver  is  properly 
carried  out,  no  especial  attempt  need  be  made  in  any  other  way 
to  guide  the  pessary  into  place,  for  it  will  rotate  into  the  lateral 
diameter  of  the  vagina  of  its  own  accord;  it  being  only  necessary 
to  see  that  it  rotates  with  the  curve  of  the  upper  or  larger  end, 


PESSARY   TREATME^JT  OF  RETRODISPLACEMENTS  167 

anterior  and  not  posterior.  Occasionally  in  spite  of  this  precau- 
tion it  will  turn  turtle,  with  the  curve  of  the  upper  end  posterior, 
so  that  a  final  examination  should  always  be  made  to  determine 
that  it  lies  in  its  correct  position  before  the  patient  is  allowed  to 


Fig.  21. — Introduction  of  Pessary:  First  Step. 


Fig.  22. — Introduction  of  Pessary;  Second  Step. 

leave  the  table.  Both  hands  can  now  be  released  and  the  labia 
separated  sufficiently  to  allow  a  thorough  inspection  when  the 
lower  or  smaller  end  of  the  pessary  should  be  seen  or  felt  to  lie 
just  under  the  symphysis.     This  should  not  press  against  the  sym- 


1 68 


STERILITY  AND   CONCEPTION 


physis  strongly  enough  to  obstruct  the  urethra  or  cause  pain  or 
discomfort  in  any  way.  When  there  is  extreme  relaxation  of  the 
vagina  and  perineum  the  pessary  may  not  be  retained  in  place 
unless  the  perineum  and  vagina  have  been  first  repaired.  Marked 
adnexal  disease  is  a  contra-indication  to  the  use  of  the  pessary. 
In  the  congenital  displacements,  those  with  a  short  anterior 
vaginal  wall,  it  will  never  effect  a  cure  unless  the  short  anterior 
wall  is  lengthened  as  a  preliminary  procedure. 

A  properly  fitted  pessary  may  be  worn  indefinitely  without 
causing  the  patient  annoyance  or  interfering  in  any  way  with  her 


Pig.  23. — Pessary  in  Place. 

marital  relations.  After  replacement,  examination  should  be 
made  at  the  end  of  a  week,  then  two  weeks,  three  weeks,  and 
four  weeks,  and  thereafter  once  every  month  to  make  sure  that 
the  uterus  stays  in  place  and  that  the  pessary  fits  properly.  The 
pessary  should  be  removed  and  the  vagina  examined  for  any 
evidence  of  erosion  at  two-month  intervals. 

Function  of  Pessary. — To  sum  up,  the  function  of  the  pessary 
is  to  hold  the  cervix  up  in  position,  thus  relieving  the  tension  on  the 
overstretched  utero-sacral  ligaments  and  giving  them,  in  common  with 
the  round  ligaments,  also  relieved  of  undue  tension  by  replacement  of 
the  fundus,  a  chance  to  regain  their  supporting  power.  The  uterus 
after  replacement  soon  regains  its  normal  tone. 


CHAPTER  XXIII 
OPERATIVE  TECHNIC 

Enlarging  the  introitus  vaginalis — Dilatation  of  the  cervix — Curettage — Enlarging 
the  external  os — Cervical  repair — Lengthening  of  the  anterior  vaginal  wall  and 
uterovesical  ligament — Abdominal  incision — Advantages  of  author's  abdominal 
incision — Retrodisplacement,  surgical  measures — Myomectomy— Operation  for 
tubal  occlusion. 


Enlarging  the  Introitus  Vaginalis. — In  cases  of  vaginismus  or 
where  dyspareunia  is  caused  by  too  small  an  opening,  median  or 


Fig.  24. 


-Enlarging  Introitus.    a-a.,  lateral  incisions, 
enlarged  vaginal  opening. 


b.,  incisions  sutured  with 


lateral  episeotomy  is  to  be  performed.  My  choice  is  for  two  lateral 
incisions.  These  are  from  one  to  one  and  a  half  inches  in  length, 
made  directly  outward  through  the  vaginal  constrictor  muscle, 
and  sewed  up  in  the  opposite  direction  from  which  they  are  made 
with  four  to  six  interrupted  sutures  of  chromic  catgut. 

Dilatation  of  the  Cervix. — A  stout  traction  forceps  grasps  the 
anterior  lip  and  draws  the  cervix  down  within  easy  access  of  the 
operator.  The  uterine  sound  is  then  passed  as  far  as  the  cavity 
of  the  uterus  to  determine  the  direction  and  length  of  the  cervical 
canal,  as  well  as  the  size  of  the  internal  os.  Frequently  the 
internal  os  will  be  found  so  small  or  so  tightly  closed  that  con- 
siderable difficulty  is  met  with  in  passing  the  sound.     In  such 

169 


i70 


STERILITY   AND   CONCEPTION 


cases  gentle  but  firm  pressure  is  made  against  it  with  the  tip  of  the 
sound  until  it  yields.  When  a  greater  degree  of  force  becomes 
necessary  the  sound,  as  it  is  introduced,  should  hug  the  roof  of  the 
cervical  canal  until  it  has  passed  the  internal  os.  By  this  pro- 
cedure puncture  of  the  cervical  uterine  segment  will  be  avoided, 
as  it  is  posteriorly  that  the  stenosis  is  most  marked,  often  by  a 
well-developed  fibrous  septum.     If  too  great  pressure  is  made 


Fig.  25. — Henrotin's  Traction  Forceps. 

against  this  it  may  deflect  the  end  of  the  sound  against  the  softer, 
less  resistant  muscular  tissues  of  the  cervix,  which  it  easily  pene- 
trates, creating  a  false  passage  between  the  folds  of  the  broad 
ligament,  or  even  into  the  peritoneal  cavity.  When  the  internal 
OS  is  not  readily  located,  the  sound  should  be  rotated  several  times 
around  its  axis,  maintaining  gentle  but  firm  pressure  meanwhile 
against  the  internal  os,  when  it  will  ultimately  find  its  own  way 
through. 


^^IMUMIMIIHJM^ «m^m..mi^W'.t 


Fig.  26. — Martin's  Uterine  Sound. 

Having,  with  the  sound,  determined  the  course  of  the  cervical 
canal  and  the  size  of  the  internal  os,  the  next  step  is  the  dilatation. 
At  the  beginning  of  this  operation,  the  slender,  rather  pointed 
Wylie's  dilator  is  often  necessary  and  should  always  be  at  hand, 
as  in  cases  of  marked  stenosis  of  the  internal  os  it  is  next  to 
impossible  to  accomplish  the  dilatation  with  any  other  instru- 
ment unless  it  be  with  the  old-fashioned  graduated  tubular 
dilators,  which  are  cumbersome,  unsatisfactory,  and  at  times  dan- 


OPERATIVE  TECHNIC 


171 


gerous.  In  introducing  the  dilator,  the  same  technic  should  be 
carried  out  as  above  described  for  the  introduction  of  the  sound, 
otherwise  the  cervix  may  be  perforated  and  the  broad  ligament 
or  peritoneal  cavity  entered  instead  of  the  uterine  cavity. 

When  the  blades  of  the  dilator  have  passed  the  internal  os,  the 
dilatation  is  begun  by  the  gentlest  of  pressure.     During  this  pro- 


Fig.  27. — Introduction  of  the  Uterine  Sound  in  Stenosis  of  the  Internal  Os. 

ceedure  all  pull  on  the  traction  forceps  should  cease  while  the 
cervix  on  the  dilator  is  pushed  up  as  far  as  it  will  go.  The  vagina 
is  thus  put  on  the  stretch,  preventing  the  cervix  from  jumping  off 
of  the  blades  of  the  dilator  as  the  dilatation  progresses.  This 
maneuver,  shown  me  many  years  ago  by  Dr.  J.  Riddle  Gofife,  if 
adopted  will  save  many  an  accidental  laceration  of  the  cervix  that 
frequently  occurs  with  the  use  of  the  Goodell  dilator.   This  instru- 


172 


STERILITY  AND  CONCEPTION 


ment,  although  in  almost  universal  use,  is  most  unsafe,  for  its 
complicated  mechanism,  designed  to  give  a  parallel  separation  of 
the  dilating  blades,  is  weak,  and  when  the  cervix  is  at  all  resistant 
they  separate  more  widely  at  the  external  than  at  the  internal  os, 
assuming  the  shape  of  a  wedge.  If  the  cervix  is  held  down  near 
the  outlet  during  the  dilatation  and  the  traction  forceps  tears  out, 
as  it  quite  often  does,  the  cervix  is  then  forced  off  of  the  dilator 
when  the  blades,  under  considerable  tension  by  reason  of  the  ten- 


Wathen  Dilator. 


Sims  Wylie  Dilator. 


Goodell  Dilator. 
Fig.  28. — Cervical  Dilators. 


sion  screw,  spring  widely  apart,  often  tearing  the  cervix  well  up 
into  the  broad  ligament.  I  have  seen  a  number  of  cases  where 
this  accident  has  happened  that  were  brought  into  the  hospital  in 
extremis  from  hemorrhage. 

After  the  dilatation  is  well  started  with  the  Sims  dilator,  a 
stronger  instrument,  such  as  the  Wathen,  which  is  much  to  be 
preferred  to  the  Goodell,  can  be  then  substituted  with  advantage. 
The  process  of  dilatation  should  be  a  slow  and  careful  one,  fifteen 
to  twenty  minutes  being  none  too  long  in  many  cases,  and  the 


OPERATIVE  TECHNIC  i73 

pressure  used  should  be  continuous  and  not  intermittent,  for  only 
in  this  way  can  a  thorough  paralyzation  of  the  cervix  be  obtained, 
and  paralyzation  is  very  necessary  if  the  uterus  is  to  be  curetted 
and  packed.  When  there  is  a  marked  degree  of  stenosis  of  the 
internal  os,  the  obstructing  septum  should  be  incised  posteriorly, 
but  never  anteriorly  or  laterally,  because  of  the  danger  of  injuring 
the  bladder  or  uterine  arteries. 

Curettage. — When  dilatation  has  been  completed  and  the  cer- 
vix thoroughly  paralyzed,  the  curettage  is  started.  This  is  best 
done  with  a  sharp  curette,  one  of  as  large  size  as  can  be  readily 
introduced.  With  great  gentleness  the  instrument  is  carried  to 
the  fundus  and  the  removal  of  the  endometrium  begun  by  a  firm 
downward  stroke  as  far  as  the  internal  os.  As  the  os  is  reached 
all  pressure  on  the  instrument  ceases  and  it  is  again  carried  care- 
fully to  the  fundus  and  the  down  stroke  repeated.  This  is  con- 
tinued until  the  entire  uterine  cavity  has  been  thoroughly  gone 
over.  While  the  uterus  is  being  curetted  strong  downward  trac- 
tion on  the  cervix  should  be  kept  up,  as  this  not  only  steadies  the 
organ  but  also  helps  to  straighten  out  any  anteflexion  present,  so 
that  the  anterior  surface  of  the  cavity  can  be  more  easily  reached. 
When  the  anteflexion  is  extreme  it  will  be  found  that  the  handle 
of  the  curette  cannot  be  depressed  suf^ciently  to  bring  the  cutting 
end  of  the  instrument  in  contact  with  the  anterior  surface  of  the 
cavity  unless  the  weighted  speculum  is  removed.  This  point  is 
worth  remembering,  and  I  have  never  seen  it  mentioned  in 
descriptions  of  the  operation. 

Upon  finishing  the  curettage,  the  cavity  is  irrigated  with  a 
normal  saline  solution  and  either  packed  or  not  as  the  indications 
may  call  for.  When  packing  is  used,  my  preference  is  for  ten-per- 
cent iodoform  gauze.  This  should  be  introduced  by  carrying  the 
end  of  the  strip  well  up  to  one  horn  of  the  cavity  and  then  packing 
across  from  side  to  side  until  the  entire  uterine  cavity  is  tightly 
filled.  As  the  cervix  is  reached,  the  packing  ceases  and  the  strip 
of  gauze  is  brought  out  straight  through  the  cervix,  vagina,  and 
introitus,  so  as  to  be  in  contact  with  the  vulvar  pad.  This  latter 
should  be  kept  wet  to  facilitate  capillary  drainage.  At  the  end  of 
three  days  the  packing  is  removed  and  a  vaginal  douche  given. 

Enlarging  the  External  Os. — Small  traction  forceps  grasp  the 
anterior  and  posterior  lips  of  the  cervix,  which  is  drawn  down 
within  easy  reach  of  the  operator  and  there  held  by  an  assistant. 


174 


STERILITY  AND  CONCEPTION 


Lateral  incisions  one-half  inch  in  length  are  then  made  from 
the  OS  outward  on  either  side. 

These  incisions  are  then  sutured  with  two  or  three  interrupted 
stitches  of  chromic  catgut  introduced  so  as  to  close  them  in  the 
opposite  direction  to  which  they  were  made. 


Fig.  29. — Operation  for  Pinhole  Os,  Exlarging  the  External  Os. 

By  this  operation  the  opening  of  the  external  os  is  increased 
to  normal  size.  A  small  strip  of  gauze  is  introduced  into  the 
cervix  as  far  as  the  internal  os  and  removed  on  the  third  day. 

Cervical  Repair. — While  the  majority  of  cervical  lacerations 
will  be  found  to  be  bilateral  and  to  call  for  the  repair  of  both  sides 
of  the  cervix,  a  certain  number  involve  only  one  side,  and  in  these 
a  unilateral  repair  is  all  that  is  indicated.  When  the  tear  is  uni- 
lateral it  will  most  frequently  be  found  on  the  left  side  and  is  often 


OPERATIVE  TECHNIC 


175 


quite  extensive.  This  is  the  type  of  laceration  most  hable  to 
involve  the  internal  os.  When  this  has  occurred  the  tear  not 
infrequently  extends  out  into  the  vagina,  perimetrium,  and  broad 
ligament.  Its  resulting  scar  can  be  easily  traced  with  the  finger 
The  vaginal  covering  of  the  cervix  will  often  unite  spontaneously 
in  such  cases,  while  the  cervical  tissue  proper  remains  widely  sep- 


FiG.  30. — Cervical  Repair,     a.,  bilateral  denudation,     b.,    method   of  introducing 

sutures 

arated.  The  eye  alone  cannot  always  detect  the  full  extent  of  the 
cervical  injury  and  should  not  be  depended  upon,  for  with  the 
uterine  sound  it  is  quite  easy  to  make  a  correct  diagnosis  of  the 
condition  of  the  internal  os,  even  though  the  external  os  may  have 
healed  to  normal  size  and  appearance. 

In  performing  cervical  repair,  each  lip  of  the  cervix  is  grasped 
with  a  pair  of  tenaculum  forceps  and  drawn  down  within  easy 


176 


STERILITY  AND  CONCEPTION 


reach.  In  some  cases  this  may  be  more  or  less  interfered  with  by 
the  restricted  mobiUty  of  the  uterus  from  adhesions  or  cicatricial 
contraction  of  the  broad  ligaments  and  vaginal  vault.  These  are 
difficult  cases  to  operate  upon  at  the  best  and  require  great  care 
and  patience. 

It  is  necessary  in  some,  and  advisable  in  most,  cases  of  cervical 
repair  to  do  a  preliminary  dilatation.     With  the  knife,  scissors,  or 


Fig.  31. — Cervical  Repair. — Sutures  tied 

both,  the  scar  tissue  is  now  removed  from  the  cervical  angles, 
together  with  any  adjacent  enlarged,  infected  glands.  A  strip 
of  mucosa  one-quarter  of  an  inch  wide  is  left  on  either  lip  to  line 
the  new  cervical  canal.  The  sutures  of  silkworm  gut  or  chromic 
catgut  are  now  introduced,  the  first  one  in  the  angle  requiring 
special  care. 

Before  passing  this  angle  stitch  the  cervical  tissue  is  caught 
high  up  in  the  angle  at  a  with  a  small  pair  of  tenaculum  forceps 


OPERATIVE  TECHNIC 


177 


and  held  firmly  down  while  the  suture  is  introduced.  The  mus- 
cular tissue  of  the  cervix  should  be  distinguished  from  the  over- 
lying, soft,  sliding  tissue  of  its  vaginal  aspect,  which  latter  is  only 
too  often  the  sole  tissue  caught  in  the  first  stitch  or  two,  the 
cervix  being  entirely  missed.  All  the  sutures  are  now  taken 
before  any  are  tied.  If  this  plan  is  not  adopted,  each  one  tied 
constricts  the  field  of  operation,  making  the  introduction  of  each 
succeeding   one    progressively    more    dif^cult,   and,    furthermore, 


Fig.  32. — Cervical  Amputation.     First  step,  cervix  drawn  down  and  circular  incision 
made  separating  the  vagina  at  its  point  of  contact. 

allows  of  the  formation  of  blood  clots  in  the  wound  that  have  to 
be  absorbed  before  union  between  the  flaps  can  take  place.  This 
very  materially  interferes  with  prompt  and  firm  healing. 

After  the  sutures  have  all  been  placed,  and  the  field  cleared  of 
clots,  they  are  tied  just  tight  enough  to  snugly  approximate  the 
tissues,  but  not  so  tight  as  to  cause  undue  constriction,  as  this 
leads  many  times  to  pressure  atrophy  and  even  necrosis. 

If  silkworm  gut  has  been  used  as  the  suture  material,  the  ends 
are  left  long  and  all  tied  together  to  facilitate  their  later  removal. 


iyS 


STERILITY  AND   CONCEPTION 


These  sutures  are  then  taken  out  on  the  fourteenth  day  by  placing 
the  patient  in  the  knee-chest  position,  retracting  the  perineum 
with  a  Sims  speculum,  grasping  the  knotted  bunch  of  suture  ends 
and  drawing  the  cervix  down  so  that  the  sutures  may  be  easily  cut 
and  removed  one  by  one.  As  the  last  suture  is  cut,  the  cervix  is 
automatically  released  and  drops  back  into  place. 


Fig.  33. — Cervical  Amputation.    Second  step. 

Cervical  Amputation. — With  a  small  traction  forceps  on  either 
lip,  the  cervix  is  drawn  strongly  down  and  held  firmly  in  position. 
A  circular  incision  with  the  knife  separates  the  vagina  from  the 
cervix  at  its  point  of  attachment,  and  by  blunt  dissection  the  cer- 
vix is  freed  from  the  surrounding  tissues.  During  this  dissection 
pressure  should  always  be  directed  against  the  cervix  to  avoid 
injury  to  the  bladder  in  front  or  the  rectum  behind.  At  either 
side,  where  the  vessels  from  the  broad  ligament  enter  the  cervix, 
the  tissues  should  be  ligated  with  catgut  close  to  the  cervix  and 


OPERATIVE  TECHNIC 


179 


then  cut.  When  the  desired  length  of  cervix  has  been  bared, 
amputation  by  transverse  incision  is  performed.  The  anterior 
and  posterior  vaginal  flaps  are  now  sewed  to  the  cervical  stump  in 
such  a  manner  as  to  cover  its  raw  surface,  leaving  the  cervical 
canal  patent  and  approximating  vaginal  and  cervical  mucosa  at 
the  new  external  os.  Deep  sutures  of  silkworm  gut  or  chromic 
gut  should  be  used  for  attaching  the  vagina  to  the  cervix,  and 


Fig.  34. — Cervical  Amputation  Completed.     Sutures  introduced  and  ready  to  tie. 


plain  catgut  for  accurate  superficial  approximation.  If  silkworm 
gut  is  used  as  suture  material  the  stitches  should  not  be  removed 
before  the  end  of  the  second  week. 

Lengthening  of  the  Anterior  Vaginal  Wall  and  Uterovesical 
Ligament. — This  operation,  quite  easy  of  accomplishment,  is  of 
extreme  importance  in  the  congenital  type  of  retrodisplacement, 
where  the  short  anterior  vaginal  wall  and  a  low  attachment  of 
the  uterovesical  ligament  hold  the  cervix  forward  in  the  axis  of 
the  vagina,  so  that  even  when  the  fundus  is  brought  forward  the 


i8o 


STERILITY  AND  CONCEPTION 


cervix  is  prevented  from  swinging  back  into  the  hollow  of  the 
sacrum  perpendicular  to  the  axis  of  the  vagina,  its  normal  posi- 
tion. 

A  transverse  incision,  one  inch  to  one  and  one-half  inches  in 
length  is  made  through  the  anterior  vaginal  wall,  at  the  point  of 


Fig.  35. — Lengthening  of  the  Anterior  Vaginal  Wall  and  Uterovesical  Liga- 
ment,    a.,  line  of  incision,     b.,  after  sutures  are  passed. 

its  attachment  to  the  vaginal  aspect  of  the  cervix.  This  point  is 
easily  determined  by  first  pulling  the  cervix  down  and  then  push- 
ing it  up,  a  procedure  which  discloses  the  fold  of  the  anterior 
vaginal  wall  on  the  cervix,  the  proper  point  at  which  to  make  the 
incision.  The  incision  is  now  carried  through  the  vaginal  wall 
and  the  uterovesical  ligament  is  dissected  out  and  cut  from  its 
uterine  attachment.     If  the  cervix  be  now  pushed  strongly  back 


OPERATIVE  TECHNIC  i8i 

towards  the  hollow  of  the  sacrum,  the  uterovesical  ligament  will 
be  seen  to  ride  up  on  the  uterus  from  half  an  inch  to  an  inch  above 
its  severed  attachment.  The  anterior  vaginal  wall  will  lengthen 
out  as  the  transverse  incision  is  converted  into  an  anterior  pos- 
terior one.  Thus  it  will  be  seen  that  the  cervix  can  now  be  car- 
ried well  back  into  the  hollow  of  the  sacrum  where  it  will  remain 
without  any  undue  tension  of  the  anterior  vaginal  wall  to  pull  it 
forward. 

The  uterovesical  ligament  is  now  sutured  with  several  chromic 
gut  sutures  to  the  uterus  at  a  point  one-half  an  inch  or  an  inch  higher 
than  its  original  attachment,  and  the  incision  in  the  vagina  is  sutured  so 
as  to  convert  the  original  transverse  incision  into  a  longitudinal 
one,  thus  lengthening  out  the  entire  vaginal  wall  at  its  cervical 
attachment  by  the  length  of  the  incision  originally  made.  Occa- 
sionally the  uterovesical  ligament  will  be  found  to  be  quite  short 
and  the  bladder  attached  quite  low  down  on  the  cervix.  In  these 
cases  the  bladder  should  be  freed  from  the  uterus  sufficiently  to 
allow  the  cervix  to  go  well  back  into  the  hollow  of  the  sacrum, 
without  any  undue  traction  on  the  bladder  itself.  When  this 
operation  is  completed,  a  suitable  pessary  should  be  introduced 
to  hold  the  fundus  forward,  and  a  light  vaginal  pack  against  the 
cervix  to  control  any  slight  oozing.  This  packing  should  be 
removed  on  the  third  day,  and  no  vaginal  douches  given  until  after 
the  tenth  day.  Douches  should  never  be  given  very  hot  in  pessary 
cases. 

Abdominal  Incision. — In  approaching  the  pelvic  organs  in  the 
female  for  the  purpose  of  surgical  treatment,  the  incision  used  should 
possess  numerous  features  advantageous  alike  to  both  operator  and 
patient. 

To  overcome  two  great  objections  to  the  median-line  incision — 
shock  and  postoperative  hernia — the  vaginal  incision  was  devised  and 
extensively  practiced.  This  incision,  while  greatly  minimizing  the 
amount  of  shock  and  practically  abolishing  postoperative  hernia,  had 
the  additional  advantage  of  affording  more  direct  access  to  the  field 
of  operation.  It  enjoyed  well-deserved  popularity,  but  that  it  had  its 
limitations  was  soon  evident.  At  the  Second  International  Congress 
for  Gynecology  and  Obstetrics,  held  at  Geneva  in  1896,  Kiistner  pre- 
sented a  new  method  of  opening  the  abdomen  in  place  of  the  median- 
line  incision.  The  cut  was  made  in  the  region  of  the  suprapubic  hair 
in  a  transverse  direction  through  the  skin  and  subcuticular  tissue,  the 


1 82  STERILITY  AND  CONCEPTION 

fascia  and  peritoneum  being  incised  vertically  in  the  median  line.  He 
advocated  this  modification  because  of  the  objection  on  the  part  of 
the  laity  to  the  deformity  caused  by  an  ugly  median-line  scar,  and 
recommended  it  for  simple  cases,  such  as  the  separation  of  adhesions 
and  ventral  fixation. 

At  the  same  congress  Rapin  presented  his  incision,  the  technic  of 
which  was  identical  in  all  respects  with  the  one  described  by  Kiistner. 
In  1900,  four  years  later,  Pfannenstiel  modified  these  by  incising  the 
fascia  likewise  in  a  transverse  direction,  separating  it  above  and  below 
from  the  underlying  muscles  and  entering  the  peritoneal  cavity  by  a 
vertical  incision  through  the  linea  alba  and  peritoneum.  Aside  from  a 
mere  cosmetic  standpoint,  his  modification  was  of  great  importance, 
for  it  was  designed  to  abolish  that  "bugbear"  of  all  abdominal  sur- 
geons— postoperative  hernia. 

The  principal  difference  between  the  Kiistner-Rapin  incision  and 
that  of  Pfannenstiel  is  that  in  the  latter  the  fascia,  being  incised  trans- 
versely, is  left  completely  intact  over  the  vertical  incision  in  the  linea 
alba,  and  the  unfavorable  tension  exerted  by  the  transverse  and  oblique 
muscles  of  the  abdomen  on  the  fascial  scar  in  the  median-line  incision 
is  disposed  of.  Pfannenstiel  hoped  that  this  incision  would  afford 
absolute  protection  from  postoperative  hernia.  I  believe  I  do  not 
exaggerate  when  I  say  that  his  dream  has  been  fully  realized.  To  him 
belongs  the  honor  of  being  the  first  to  plan,  execute,  and  publish  the 
transverse  fascial  incision,  which  had  been  independently  practiced, 
however,  by  both  Stimson  of  New  York  and  Hartman  of  Paris.  The 
Pfannenstiel  incision  overcame  many  of  the  objections  to  both  the 
median-line  and  vaginal  incisions,  and  its  many  advantages  were  so 
apparent  that  it  met  with  immediate  and  almost  universal  favor.  An 
extensive  trial  of  this  incision  has  led  m.e  to  make  certain  modifications 
and  changes  in  his  technic  which  I  believe  better  meet  the  require- 
ments of  the  average  case.  It  is  because  of  these  rather  radical  changes 
that  I  give  a  detailed  description  of  the  incision  as  I  make  it. 

TECHNIC 

With  the  patient  in  the  Trendelenburg  position  (45°  elevation), 
a  transverse  incision  2  to  4  inches  in  length  is  made  in  the  edge  of  the 
suprapubic  hair,  or  in  the  transverse  skin  fold  usually  found  just  above 
it.  A  straight  cut  is  used  rather  than  a  semilunar  one,  because  ex- 
perience has  shown  that  It  severs  fewer  blood-vessels,  giving  rise  to 


I.  The  transverse  incision,  with  the'pyramidal  and  the  abdominal  recti  muscles  exposed. 


2.  The  right  pyramidalis  drawn  aside  and  the  recti  separated. 


3.  The  incision  and  separation  of  the  muscles  and  fascia  completed,  with  the  pelvic 

cavity  and  organs  exposed. 
Fig.  36. — Author's  Transverse  Suprapubic  Abdominal  Incision, 

183 


i84  STERILITY    AND   CONCEPTION 

less  hemorrhage  and  causing  less  interference  with  the  subsequent 
nutrition  of  the  flaps.  It  is  seldom  necessary  to  ligate  more  than  two 
or  three  blood  vessels  in  the  wound,  and  often  no  ligatures  at  all  are 
needed,  thus  greatly  reducing  the  amount  of  foreign  material  intro- 
duced into  the  wound,  all  of  which  has  an  important  bearing  on 
subsequent  wound-union. 

The  wound  is  now  stretched  with  the  fingers,  thereby  slightly 
enlarging  it  and  better  exposing  the  underlying  fascia,  which,  after 
operation,  contract  to  the  original  size  of  the  cut.  The  fascia  is  next 
incised  in  the  same  direction  and  to  the  same  extent,  i  to  2  inches 
above  the  symphysis  pubis.  The  extent  of  the  fascial  incision  to 
either  side  should  be  limited  by  the  outer  borders  of  the  recti  muscles, 
and  if  a  larger  opening  is  required,  the  incision  should  be  curved 
upward  or  follow  the  outer  borders  of  the  rectal  sheaths  directly 
upward,  to  avoid  injury  to  the  inguinal  canals.  Dissecting  the  fascial 
flaps  free  from  the  underlying  muscles,  which  can  readily  be  done  by 
blunt  dissection  with  the  finger  from  without  inwards  (the  linea  alba 
must  be  cut  with  the  scissors),  discloses  the  two  recti  overlapped  by  the 
pyramidali.  The  right  pyramidalis  is  separated  at  its  outer  edge  from 
the  underlying  rectus,  but  not  from  the  linea  alba,  and  retracted  to  the 
middle  line.  Under  this  the  rectus  is  separated  from  the  middle  line 
and  retracted  outward. 

The  peritoneum  now  lies  exposed,  and  the  abdominal  cavity  is 
opened  by  a  vertical  incision.  The  lower  flap  is  retracted  by  a  self- 
retaining  retractor,  preferably  that  of  Doyen,  and  the  upper  one  by 
a  small  movable  abdominal  retractor. 

These  are  the  only  permanent  retractors  required.  Of  great  assist- 
ance during  the  remainder  of  the  operation  are  two  trowels,  which 
make  possible  perfect  retraction  in  what  would  otherwise  be  inac- 
cessible portions  of  the  operative  field.  These  can  be  made  to  illumi- 
nate many  a  dark  area  with  light  caught  by  and  reflected  from  their 
polished  surface. 

When  the  operation  is  completed,  the  wound  is  closed  in  three 
separate  layers — peritoneum,  fascia,  and  skin. 

Advantages. — The  abdominal  opening  afforded  by  this  incision  is 
in  close  proximity  to  the  pelvic  organs  and  directly  above  them. 

The  operator  works  to  greatest  advantage,  as  the  opening  centers 
the  field  of  operation,  and  he  has  free  access  in  every  direction 
without  being  obliged,  as  Kelly  says,  "to  work  in  the  lower  angle 
of  a  rigid  'V'." 


OPERATIVE   TECHNIC 


185 


Retraction  is  easy,  as  the  muscles,  being  freed  from  their  over- 
lying fascia,  are  readily  drawn  aside  and  can  be  kept  out  of  the  way 
with  the  use  of  very  little  force  on  the  retractors.  As  the  long  axis 
of  the  incision  runs  in  the  same  direction  as  the  pelvic  organs,  from  the 
adnexa  on  one  side  across  the  fundus  and  adnexa  of  the  other  side,  a 
maximum  exposure  of  the  field  of  operation  is  afforded  by  a  minimum 
length  incision. 


Cross-section  of  abdominal  wall  showing  path  of  entrance  to  abdominal  cavity  in 
median  line  incision  and  in  Pfannenstiel  transverse  incision.  The  recti  muscles 
are  widely  separated  and  the  subsequent  strength  of  the  wound  depends  on  fascial 
union  only. 


Cross-section  of  abdominal  wall  at  site  of  incision  showing  path  of  entrance  to  abdomina 
cavity  by  the  author's  low  transverse  suprapubic  incision.  The  recti  lie  close 
together  with  no  fascial  separation  and  the  wound  is  further  strengthened  by  the 
overlapping  pyramidali  muscles.  This  incision  affords  the  surest  guarantee 
against  post-operative  hernia. 

Fig.  37. — Transverse  Suprapubic  Abdominal  Incision. 

The  advantages  derived  by  the  patient  on  whom  this  incision  is 
used  are  of  extreme  importance:  (i)  The  comparative  freedom  from 
shock  and  postoperative  complications  is  quite  noticeable  when  using 
this  method  after  the  old  median-line  incision;  (2)  the  perfect  expos- 
ure, with  the  ease  of  access  to  the  pelvic  organs  which  it  affords, 
greatly  limits  the  amount  of  intra-abdominal  manipulations  necessary ; 
(3)  the  intestines  are  kept  in  place,  well  covered  and  amply  protected 


1 86  STERILITY  AND   CONCEPTION 

by  the  upper  flap;  (4)  few,  if  any,  laparotomy  pads  are  required, 
except  in  pus  cases,  all  of  which  items  greatly  reduce  the  amount  of 
intraperitoneal  traumatism  and  give  a  convalescence  proportionately 
smooth. 

With  the  transverse  abdominal  incision  the  tendency  to  post- 
operative hernia  is  reduced  to  a  minimum,  and  I  do  not  hesitate  to  say 
that  such  a  complication  with  the  incision  which  I  have  described  is 
practically  impossible.  I  have  never  encountered  or  heard  of  a  case, 
and  my  interest  in  the  subject  has  made  me  more  than  ordinarily 
vigilant. 

The  incision  is  intermuscular,  made  in  the  strongest  part  of  the 
abdominal  wall,  the  lower  third  of  the  distance  between  the  symphysis 
pubis  and  the  umbilicus,  a  region  most  abundantly  supplied  with 
strong  muscular  tissue,  and  one  where  spontaneous  hernia  is  seldom, 
if  ever,  seen.  Here  the  recti,  two  strong  thick  muscles,  lie  close  to- 
gether, and  are  further  strengthened  by  the  overlapping  pyramidali. 
On  the  other  hand,  the  upper  two-thirds  of  the  distance  between  the 
symphysis  pubis  and  the  umbilicus  is,  with  the  exception  of  the 
abdominal  rings,  the  weakest  part  of  the  abdominal  wall,  where  spon- 
taneous hernia  is  often  seen.  Here  the  recti  broaden  and  thin  out, 
separating  to  pass  the  umbilicus  above,  and  the  additional  support  to 
the  pyramidalis  is  lost.  Hernia  here  frequently  results  from  the 
simple  separation  of  the  recti  and  thinning  of  the  fascia  of  the  linea 
alba  consequent  to  the  stretching  produced  by  the  enlarged  uterus  of 
pregnancy  or  an  abdominal  tumor — by  all  means  a  region  to  keep 
away  from  and  not  to  further  weaken  by  operative  invasion. 

To  secure  the  strongest  wound  after  operation,  the  incision  should 
be  made  in  the  strongest  part  of  the  abdominal  wall,  and  by  a  technic 
that  interferes  as  little  as  possible  with  the  integrity  of  the  fascia  and 
muscles. 

Just  behind  the  peritoneal  scar  of  this  incision  lies  the  bladder, 
which,  as  it  fills,  pushes  intestines  away,  preventing  them  from 
adhering  to  the  wound.  In  none  of  the  cases  in  which  I  have  had 
occasion  to  reopen  the  abdomen  did  any  such  adhesions  exist. 

The  drawings  show  in  cross-section  the  path  of  entrance  to  the 
abdominal  cavity  in  my  incision  and  in  that  of  Pfannenstiel.  In  mine 
the  recti  are  close  together,  the  linea  alba  a  line  only,  and  if  the  intes- 
tines should  work  their  way  through  this  narrow  space  between  the 
recti,  the  pyramidalis  would  have  to  be  passed  before  the  fascia  was 
finally  reached. 


OPERATIVE   TECHNIC 


187 


In  Pfannenstiel's  the  recti  lie  farther  apart  and  are  not  so  thick. 
The  Hnea  alba  is  broad  and  is  cut  to  free  the  recti;  so,  if  weakened  as 
a  result  of  the  operation,  they  would  more  readily  yield  to  any  advance 
of  the  intestines,  and  the  main  resistance  of  the  abdominal  wall 
would  then  depend  solely  on  the  fascia. 

It  has  been  my  experience  that  the  straight  transverse  incision 
severs  fewer  blood-vessels  of  any  size  than  the  curved  transverse  or 
median-line  incision,  as  it  appears  to  parallel  the  larger  vessels  in  the 
suprapubic  region,  and  as  few  are  cut,  there  is  a  minimum  inter- 


FiG.  38. — Author's  Tubal  and  Intestinal  Forceps,  with  Rubber  Jaws. 


ference  with  subsequent  tissue  nutrition,  and  little  necessity  for  the  use 
of  ligatures — two  most  potent  causes  of  wound  infection.  Likewise 
the  perfect  exposure  of,  and  easy  access  to,  the  field  of  operation  limit 
greatly  the  traumatism  inflicted  on  the  tissues  from  frequently  shifted 
retractors.  The  retractor  of  the  lower  wound-flap,  when  once  placed, 
is  permanent  throughout  the  operation,  while  the  retractor  of  the 
upper  flap  is  not  often  moved.  The  trowel  retractors,  the  only  ones 
frequently  moved,  seldom  touch  the  edges  of  the  wound. 

The  cosmetic  result  leaves  little  to  be  desired.  After  six  months  or 
a  year  the  fine,  unpigmented  cicatrix  is  hardly  to  be  seen,  and  if  sit- 
uated in  the  pubic  hair  is  completely  hidden  from  view — a  minor  point 


i88 


STERILITY  AND   CONCEPTION 


possibly,  but  worth  considering  in  patients  with  neurasthenic  tend- 
encies, where  a  visible  abdominal  scar  serves  ever  as  a  constant 
reminder  of  the  past. 

This  incision  is  an  ideal  one  for  pelvic  surgery  in  the  female. 


Fig.  39. — ^Author's  Self-retaining  Abdomin.^l  Retractor. 

Closure  of  the  Abdominal  Incision. — In  closing  the  incision 
through  the  abdominal  wall  after  operation,  three  structures  need 
accurate  apposition  in  order  to  restore  the  normal  anatomical  relations. 
These  are  the  peritoneum,  fascia,  and  skin.  The  muscles,  provided 
they  have  been  subjected  to  no  further  traumatism  than  the  necessary 
displacement  or  separation  of  their  fibers,  require  no  retaining  sutures. 


Fig.  40. — Author's  Trowel  Retractor. 

In  holding  the  tissues  together  until  union  has  taken  place,  it  is 
desirable  to  use  as  few  sutures  as  possible,  for  every  one  introduced 
produces  some  pressure  atrophy,  is  a  foreign  body,  and  increases  the 
chances  of  infection.  The  sutures  should  be  so  introduced  as  to  accom- 
plish their  purpose  without  strangulation  of  the  tissues  which  they 
unite,  for  where  the  sutures  are  tied  in  the  wound  the  nutrition  of  the 


OPERATIVE   TECHNIC 


189 


tissues  they  include  is  interfered  with,  and  atrophy,  if  not  actual 
necrosis,  results.  This  is  particularly  true  of  the  fascia,  more  poorly 
nourished,  as  it  is,  than  either  the  peritoneum  or  the  skin.  Moreover, 
the  tying  of  knots  in  the  wound  greatly  increases  the  amount  of 
foreign  material  introduced  that  later  must  become  absorbed  or 
encysted. 

Tech  NIC. — The  peritoneum  is  brought  together  by  a  continuous 
suture  of  fine  kangaroo  tendon.  The  fascia  is  united  by  a  running 
quilted  stitch  of  medium  size  tension  suture  material  drawing  the  raw 
edges  together  without  undue  tension,  and  instead  of  being  tied  in  the 


"144- 


Fig.  41. 


-Closure  of  Abdominal  Incision;   Author's  Method,     i,  introduction  of 
sutures.     2,  sutures  ready  to  tie.     3,  sutures  tied  over  gauze. 


wound  the  ends  are  brought  out  through  the  skin  and  left  long  near  the 
angles  of  the  wound. 

The  incision  in  the  skin  is  closed  in  the  same  way  by  a  continuous 
subcuticular  stitch  of  the  same  material,  and  the  ends  are  also  brought 
out  through  the  skin  and  left  long  near  the  angles  of  the  wound,  but 
on  the  opposite  sides  from  the  fascial  stitch. 

A  firm  roll  of  gauze,  one  inch  thick  and  slightly  longer  than  the 
wound,  is  now  laid  over  it,  and  over  this  at  each  end,  the  skin  and 
fascial  stitches  are  tied  together  in  a  bow  knot,  just  tight  enough  to 
take  up  any  sHpping  that  may  have  occurred  in  the  fascial  stitch  since 
its  introduction.  At  the  first  dressing  on  the  third  day  the  gauze 
between  these  knots  is  cut  out  so  as  to  allow  subsequent  daily  inspec- 
tion of  the  wound. 


I  go 


STERILITY  AND  CONCEPTION 


At  the  end  of  the  second  week  the  knots  are  untied,  releasing  the 
remaining  ends  of  the  gauze  roller,  the  sutures  cut  off  at  one  end  and 
drawn  out,  thus  leaving  no  suture  material  behind  in  the  wound 
between  the  peritoneum  and  skin. 

In  case  there  is  failure  on  the  part  of  the  wound  to  heal  by  primary 
union  the  skin  stitch  should  be  withdrawn  and  the  fascial  incision 
inspected.  If  this  shows  infection  or  if  the  infection  is  under  the 
fascia,  its  edges  can  be  readily  separated  by  loosening  the  sutures  with- 
out removing  it,  and  proper  drainage  secured.    Later,  when  the  infec- 


FiG.  42. — Transverse  Suprapubic  Abdominal  Incision  Two  Weeks  after 

Operation. 


tion  has  subsided  and  union  begun,  the  edges  of  the  fascia  can  again 
be  drawn  together  and  good  approximation  obtained.  Thus,  the  intro- 
duction of  secondary  sutures  to  close  the  separation  in  the  fascia  so 
often  observed  to  follow  suppurating  wounds,  and  such  a  frequent 
cause  of  postoperative  hernia,  is  avoided,  saving  much  annoyance  to 
both  patient  and  surgeon.  This  method  of  closure  yields  95  to  98 
per  cent  primary  union. 

Retrodisplacement. — In  a  discussion  of  the  operative  treat- 
ment of  retrodisplacement,  I  shall  make  no  attempt  to  describe  or 
even  enumerate  the  great  number  of  operations  that  have  from 
time  to  time  been  devised.     Many  are  good;  some  decidedly  bad. 


OPERATIVE  TECHNIC  191 

I  do  not  believe  in  the  creation  of  new  supports  or  attachments 
for  the  uterus.  The  round  and  uterosacral  Ugaments  are  the 
factors  most  concerned  in  maintaining  the  normal  position  of  the 
uterus,  and  are  likewise  the  ones  most  easy  of  surgical  attack. 
So  long  as  the  uterosacral  ligaments  hold  the  cervix  up  in  the 
hollow  of  the  sacrum,  just  so  long  will  the  fundus  remain  forward ; 
but  when  the  uterosacral  ligaments  become  relaxed  and  allow  the 
cervix  to  swing  down  into  the  axis  of  the  vagina,  then  the  con- 
ditions are  changed,  and  the  fundus,  if  the  round  ligaments  are  not 
equal  to  holding  it  forward,  tends  to  drop  back  into  a  position  of 
retroversion  or  retroflexion.  In  those  cases  of  retrodisplacement 
where  there  is  only  a  slight  descent  of  the  cervix  the  shortening 
of  the  round  ligaments  will  usually  sufiftce. 

The  round  ligament  shortening  may  be  done  by  either  the 
abdominal  or  vaginal  route.  The  shortening  of  the  uterosacral 
ligament  can  be  done  to  best  advantage  only  by  the  abdominal 
route.  Therefore,  while  I  have  in  the  past  been  just  as  enthu- 
siastic about  the  vaginal  method  of  approach  as  have  many  of 
my  colleagues,  more  mature  judgment  based  on  a  further  study 
of  abdominal  technic,  especially  since  the  advent  of  the  trans- 
verse, suprapubic  incision,  has  led  me  to  adopt  the  abdominal 
method  as  the  one  of  election,  and  I  give  the  following  technic  as 
the  one  of  my  choice. 

OPERATION 

With  the  patient  in  the  Trendelenburg  position  (45°  angle),  the 
intestines  will  gravitate  out  of  the  pelvis,  thus  doing  away  with  the  use 
of  laparotomy  pads.  A  transverse  suprapubic  incision  two  inches  in 
length  and  about  the  same  distance  above  the  symphysis  pubis  is  now 
made.  This  is  carried  through  all  tissues  including  the  fascia  down 
to  the  muscles.  As  the  fascia  is  incised,  the  sheaths  of  the  recti  are 
opened  and  the  linea  alba  is  seen  in  the  middle  of  the  incision  on  either 
side  of  which  lie  the  vertical  fibers  of  the  recti  muscles.  In  about  fifty 
per  cent  of  cases,  the  slightly  oblique  fibers  of  the  pyramidali  muscles 
are  seen  overlapping  the  recti  in  the  lower  and  middle  third  of  the  field 
of  operation.  When  the  pyramidali  are  well  developed  they  should  be 
saved,  for  they  are  the  tensor  muscles  of  the  fascia  in  the  linea  albi, 
and  their  loss  may  lead  later  to  a  wide  separation  of  the  recti  muscles. 
The  right  pyramidalis  is  now  freed  from  its  slight  attachment  to  the 


192  STERILITY  AND   CONCEPTION 

underlying  rectus  and  drawn  toward  the  linea  alba.  The  rectus  is 
then  freed  from  the  linea  alba  drawn  outward.  This  discloses  the 
posterior  sheath,  which  in  this  location  is  composed  only  of  peri- 
toneum. The  peritoneum  is  now  incised  either  longitudinally  or  trans- 
versely, opening  the  peritoneal  cavity. 

When  the  patient  is  properly  anesthetized  and  a  full  forty-five 
degree  elevation  of  the  table  maintained,  the  intestines  will  gravitate 
out  of  the  field  of  operation  in  the  pelvis,  or  can  be  readily  made  to  do 
so  with  very  little  help,  so  that  laparotomy  pads  need  not  be  used. 
The  use  of  pads,  in  other  than  pus  cases,  is  a  needless  insult  to  the 
viscera,  which  they  are  quick  to  resent,  and  which  is  very  frequently 
followed  by  a  stormy  convalescence,  out  of  all  proportion  to  the 
operative  indications  in  the  case.  The  incision  is  now  retracted  above 
and  below,  any  adhesions  freed,  the  adnexa  treated  as  may  be  indi- 
cated and  the  uterus  replaced.  Each  round  ligament  in  turn  is  now 
grasped  with  a  pair  of  compression  forceps  at  its  mid-point  between 
the  uterus  and  the  internal  inguinal  ring  and  drawn  upwards,  develop- 
ing a  loop  for  suturing.  With  a  small,  round,  pointed  needle,  threaded 
with  medium  size  silk  or  linen  thread,  the  ligament  is  transfixed  about 
one  inch  from  the  inguinal  ring  and  again  at  its  origin  from  the 
uterus.  Occasionally  the  origin  of  the  round  ligament  will  vary  and 
it  will  at  times  be  found  to  come  off  low  down  near  the  waist  of  the 
uterus.  When  this  is  the  case,  the  second  passage  of  the  needle  should 
be  through  the  uterine  tissue,  just  anterior  to  the  tube,  so  that  when 
the  shortening  is  accomplished  the  pull  of  the  ligament  will  be  from 
the  fundus  and  not  from  a  point  lower  down  on  the  anterior  uterine 
wall,  as  this  would  tend  to  pull  the  cervix  forward  rather  than  the 
fundus.  The  suture  transfixes  the  ligament  but  does  not  completely 
surround  it.     In  this  way  its  nutrition  is  not  interfered  with. 

The  suture  is  now  tied  and  another  one  is  similarly  passed  midway 
between  the  first  one  and  the  end  of  the  ligament  loop.  This  gives  a 
total  shortening  of  the  ligament  twice  the  length  of  the  loop,  usually 
from  four  to  six  inches.  The  end  of  the  loop  is  then  transfixed  with 
a  suture  of  catgut  or  kangaroo  tendon,  and  so  sutured  to  the  anterior 
uterine  wall  as  to  bury  under  its  folds  the  two  nonabsorbent  sutures 
with  which  it  was  shortened.  This  is  done  to  prevent  them  coming  in 
contact  with  the  bladder  wall,  through  which  they  might  easily  migrate, 
and  form  within  the  bladder  a  nidus  for  the  growth  of  a  calculus. 
When  the  round  ligament  of  the  opposite  side  has  been  similarlv 
shortened,  it  will  be  seen  that  the  fundus,  even  with  the  patient  in  the 


OPERATIVE  TECHNIC  193 

Trendelenburg  position,   has   been  brought  well   forward,   where   it 
remains  without  any  tendency  to  retrodisplacement. 

A  trowel  retractor  is  now  passed  along  the  posterior  wall  of  the 
uterus  and  by  firm  pressure  the  uterus  is  carried  well  forward, 
especially  its  cervical  portion,  when  the  uterosacral  ligaments  can  be 
easily  demonstrated  as  reduplicated  folds  of  peritoneum  running  from 
the  waist  of  the  uterus  upward  to  either  side  of  the  rectum.    These  are 


i 


Fig.  43.— Round  Ligament  Shortening.  Tfic  left  ligament  has  been  shortened  and 
the  redundant  loop  sutured  in  place.  The  right  ligament  is  caught  up  and  the, 
first  suture  introduced. 

now  picked  up  in  turn,  developing  a  loop  about  two  inches  in  length. 
A  permanent  shortening  of  each  ligament  is  then  made,  as  in  the  case 
of  the  round  ligaments.  The  operation  in  the  pelvis  is  now  completed, 
excepting  in  those  cases  where  a  retroflexion  has  existed  for  some 
length  of  time.  In  these,  the  angle  of  flexion  may  still  persist,  even 
though  the  fundus  has  been  brought  well  forward,  so  that  it  is  neces- 
sary to  break  up  the  impaction  at  the  angle  of  flexion  by  strongly 
bending  the  fundus  forward  on  the  cervix.     This  Is  accomplished  by 


194  STERILITY  AND   CONCEPTION 

laying  the  index  finger  of  the  right  hand  against  the  cervix  and  passing 
the  middle  finger  over  and  back  of  the  fundus,  when  by  puUing  the 
fundus  strongly  forward  with  the  middle  finger  and  pressing  the  index 
finger  against  the  cervix,  the  uterus  is  converted  into  an  extreme  ante- 
flexion. When  the  pressure  is  released  the  fundus  gradually  assumes 
a  normal  position  of  anteversion. 

The  peritoneal  incision  is  then  closed  by  a  suture  of  fine-sized 
kangaroo  tendon,  during  the  introduction  of  which  the  table  is  grad- 
ually lowered  to  a  horizontal  position.  The  fascia,  fat,  and  skin  are 
united  by  continuous  mattress  sutures  of  large-size  silkworm  gut, 
silver  wire,  or  preferably  one  of  the  substitutes  known  as  tension 
suture  material,  manufactured  by  a  number  of  well-known  surgical 
supply  houses.  In  cases  where  the  uterus  is  quite  large  and  the  liga- 
ments small  or  the  uterosacral  ligaments  congenitally  absent,  a  pessary 
should  be  fitted  while  the  patient  is  still  under  the  anesthetic.  It 
should  be  worn  for  three  or  four  months  after  operation.  Excepting 
in  those  cases  where  a  pessary  has  been  fitted,  the  patient,  during  her 
convalescence,  should  not  assume  a  dorsal  position  in  bed,  but  should 
be  kept  in  the  face  or  exaggerated  Sims  position.  When  pregnancy 
occurs,  a  pessary  should  be  worn  for  the  first  four  months  and  again 
for  six  months  post  partum. 

MYOMECTOMY 

In  the  surgical  treatment  of  the  fibroid  uterus  the  multiplicity 
of  the  tumors  and  the  large  size  of  the  tumor  mass  often  add  very 
materially  to  the  difficulty  of  removal.  "The  larger  the  tumor  the 
larger  the  incision,"  is  the  time-honored  dictum.  These  opera- 
tions may  be  greatly  facilitated  by  decreasing  the  bulk  of  the 
tumor  mass  as  the  removal  proceeds,  and  this  method  of  removal 
means  greater  safety  to  the  patient. 

Ordinarily,  these  tumors  are  removed  through  a  large  median- 
line  incision,  the  size  of  the  incision  being  proportionate  to  the 
size  of  the  growth.  The  intestines  are  then  packed  out  of  the  way 
with  laparotomy  pads,  the  uterus  delivered,  and  myomectomy  per- 
formed.   This  method  of  procedure  has  the  following  objections: 

I.  A  large  median-line  incision  gives  a  high  percentage  of 
postoperative  hernia,  both  primary  and  secondary,  and  there  is 
too  great  an  exposure  of  the  abdominal  viscera  during  the  opera- 
tion. 


OPERATIVE  TECHNIC  19 S 

2.  Laparotomy  pads  traumatize  the  intestine,  adding  to  the 
danger  of  iHus  and  postoperative  infection.  Exposure  and  trauma- 
tism of  the  viscera  are  of  very  grave  importance,  and  in  every 
abdominal  operation  should  be  reduced  to  the  lowest  possible 
minimum.  Laparotomy  pads,  always  a  menace  to  the  patient,  are 
unnecessary  in  most  abdominal  operations.  In  the  removal  of 
fibroids  they  constitute  a  needless  insult  to  the  viscera. 

My  operative  technic  is  as  follows: 

With  the  peritoneal  cavity  open,  the  wound  properly  retracted 
above  and  below,  the  pathological  condition  is  studied,  and  the 
question  of  myomectomy  decided.  The  tumor  mass  is  then 
grasped  with  two  heavy  traction  forceps,  held  in  close  apposition 
to  the  abdominal  wall  and  the  removal  begun.  Small  tumors  are 
enucleated  and  removed  entire,  while  those  too  large  to  pass 
through  the  incision  are  morcellated.  This  decreases  the  bulk  of 
the  tumor  mass,  and,  as  the  operation  proceeds,  each  successive 
step  becomes  progressively  easier.  During  the  process  of  mor- 
cellation  the  tumor  mass  is  kept  constantly  in  contact  with  the 
abdominal  wall.  This  excludes  the  intestines  from  the  field  of 
operation,  preventing  their  injury  from  traumatism  or  prolonged 
exposure,  and  eliminates  the  necessity  for  laparotomy  pads.  As 
the  operation  is  largely  extraperitoneal,  the  convalescence  is  pro- 
portionately smooth.  There  is  a  notable  freedom  from  distention 
following,  and  the  danger  of  subsequent  adhesions  is  minimized. 
When  adherent  viscera  are  encountered  they  are  drawn  up  into 
the  wound  and  separated  under  the  eye,  where  they  can  be  easily 
and  safely  dealt  with.  As  the  morcellation  proceeds,  the  tumor 
decreases  in  size,  the  round  and  broad  ligaments,  relieved  of 
tension,  relax,  and  it  now  becomes  easy,  if  desirable,  to  deliver  the 
uterus  through  the  wound. 

The  advantages  of  myomectomy  by  morcellation  are  many. 
The  original  morcellation  by  the  vaginal  route  enjoyed  great 
popularity  because  of  the  smoothness  of  the  subsequent  con- 
valescence and  freedom  from  postoperative  complications,  both 
immediate  and  remote.  The  abdominal  removal  of  these  tumors 
by  morcellation,  now  that  we  have  to-day  so  improved  our  abdom- 
inal technic,  gives  just  as  smooth  a  convalescence  and  just  as  great 
a  freedom  from  complications  as  was  secured  by  the  vaginal 
operators  in  the  past. 

The  advantages  of  the  technic  which  I  have  above  outlined 


196  STERILITY  AND  CONCEPTION 

may  be  considered  both  from  the  point  of  view  of  the  patient  and 
of  the  surgeon.  To  the  patient  it  affords  greater  safety,  a  shorter 
and  a  smoother  convalescence.  This  is  by  reason  of  the  fact  that 
as  the  surgeon  works  practically  extraperitoneally  the  intestines 
are  kept  out  of  the  way  without  resource  to  laparotomy  pads ;  thus 
is  the  intraperitoneal  traumatism  minimized  and  postoperative 
shock,  distention,  or  peritonitis  seldom,  if  ever,  seen.  The  smaller 
incision  and  the  stronger  resulting  scar,  especially  when  the  trans- 
verse incision  is  used,  reduces  to  a  minimum  the  danger  of  hernia. 
The  high  percentage  of  primary  union  resulting  when  the  trans- 
verse incision  is  closed  with  non-infectible  suture  material,  means 
a  much  shorter  hospital  residence.  A  large  granulating  median- 
line  incision  where  primary  union  has  not  been  secured  means  a 
prolongation  of  the  convalescence  by  many  weeks,  with  a  good 
prospect  of  subsequent  hospital  stay  when  the  ventral  hernia, 
almost  certain  to  occur  in  such  a  case,  is  repaired. 

During  the  greater  part  of  the  operation  the  tumor  is  in  con- 
tact with  the  abdominal  wall,  so  that  the  work  is  largely  extra- 
peritoneal. Thus  is  the  surgeon  able  to  see  definitely  each  patho- 
logical condition  as  it  arises,  and  to  take  the  necessary  time  to 
meet  the  indication,  for  by  this  technic  the  length  of  time  which 
the  patient  is  under  the  anesthetic  is  not  nearly  of  the  importance 
that  it  is  when  a  laf  ge  median-line  incision  has  been  made  with  all 
the  consequent  exposure  of  intestines  and  use  of  laporotomy  pads 
that  go  with  the  older  technic.  Although  the  transverse  supra- 
pubic incision  may  be  so  small  as  to  handicap  many  an  operator 
at  the  start,  still  as  skill  in  anything  is  acquired  only  by  repetition, 
so  here  with  experience  one  quickly  becomes  proficient. 

TUBAL  OCCLUSION 

At  the  meeting  of  the  American  Gynecological  Society,  held  in 
Chicago,  May  24,  1920,  I  reported  seven  cases  of  tubal-occlusion 
sterility  cured  by  operation.  These  women  subsequently  bore 
eight  living  children,  and  five  are  still  in  the  child-bearing  period. 
In  one  case  the  sterility  was  of  seven  years'  duration,  yet  the  baby 
was  born  ten  months  after  operation.  Such  results  as  these  I 
feel  should  go  far  towards  combating  the  growing  pessimism  of 
the  profession  on  this  subject. 

The  more  carefully  the  cases  are  worked  up  the  less  frequent 
becomes  the  necessity  of  depending  upon  a  diagnosis  arrived  at  by 


OPERATIVE  TECHNIC  197 

elimination.  Possibility  yields  to  probability,  and  as  our  skill  in 
observation  and  deduction  increases,  the  etiological  factor  will 
often  be  found  with  quickness  and  certainty. 

Operation. — Through  the  abdominal  incision  already  described 
the  adnexa  are  exposed  and  carefully  inspected.  All  adhesions  are 
freed  and  the  tubes  separated  from  any  pathological  attachment 
and  carefully  inspected.  Next  comes  the  opening  of  the  tubes, 
and  here  variations  in  technic  are  at  times  necessary.  If  the 
tubal  end  has  been  occluded  from  without,  as  is  the  case  where 
direct  adhesion  to  the  broad  ligament  or  neighboring  peritoneal 
surfaces  results  from  postabortive  or  postpartum  peritonitis,  then 
the  freeing  of  the  tubal  end  at  once  opens  its  lumen,  disclosing  the 
fimbria,  and  calls  for  nothing  further.  Where  the  occlusion  is  the 
result  of  a  previous  gonorrhea  the  fimbriae  are  found  drawn  into 
the  lumen  of  the  tube  and  the  tube  enlarged  by  the  presence  of 
more  or  less  fluid  (hydrosalpinx).  A  close  inspection  of  such  a 
tube  will  usually  reveal  a  dimple  which  marks  the  point  of  closure. 
At  this  point  the  tube  can  be  readily  entered  by  pressure  with  a 
pair  of  small-nosed  artery  clamps,  the  fluid  evacuated,  and  then, 
by  separating  the  jaws  of  the  artery  clamp,  the  slight  adhesion 
imprisoning  the  fimbriae  is  readily  freed  and  by  milking  the  tube 
between  the  thumb  and  index  finger  the  fimbriae  are  readily  forced 
out  from  the  interior  of  the  tube  to  their  normal  situation.  Hav- 
ing cleared  the  end  of  the  tube,  a  fine-size  lachrymal  probe  or  the 
author's  fallopian  probe  is  then  passed  along  the  tube  and  through 
the  cornual  end  into  the  uterine  cavity,  to  establish  the  patency 
of  the  canal.  Occasionally  the  probe  will  encounter  obliterated 
points  in  the  tube,  which,  with  a  little  persistence,  can  be  readily 
passed.  In  passing  these  obstructions,  great  gentleness  should 
be  used  to  prevent  the  probe  puncturing  the  wall  of  the  tube.  It 
is  usually  better  in  carrying  out  this  procedure  to  thread  the  tube 
on  the  probe,  which  is  meanwhile  held  stationary,  than  it  is  to 
attempt  to  push  the  probe  onward  past  the  obstruction.  Rarely 
will  it  be  found  that  the  site  of  occlusion  of  the  tube  is  at  the 
cornual  end  or  at  any  point  other  than  the  distal  end.  Having 
now  opened  both  tubes  and  established  their  patency,  there  is 
nothing  further  to  be  done  except  to  ligate  the  few  bleeding  points 
generally  found  around  the  opening  at  the  end  of  the  tube  where 
the  fimbriae  have  been  freed.  These  areas  bleed  very  actively  for 
some  time  if  not  controlled  by  ligatures.  In  cases  where  the  dis- 
ease in  the  tube  has  resulted  in  extensive  obliteration  of  its  lumen, 


igS 


STERILITY  AND  CONCEPTION 


it  may  be  necessary  either  to  remove  the  obUterated  area  of  the 
tube  or  to  make  a  new  opening  (salpingostomy)  in  the  tube  at 
some  point  between  the  uterus  and  the  obstructed  area.  Person- 
ally I  prefer  the  former  method,  which  is  carried  out  as  follows: 

The  obstructed  portion  of  the  tube  is  gradually  removed  until 
the  free  lumen  is  reached.  The  diseased  portion  is  now  cut  away 
and  after  it  has  been  established  by  probing  that  there  is  no 
obstruction  in  the  remainder  of  the  tube,  its  freed  end  is  slit  along 
the   dorsum    for   three-quarters   of   an    inch.      With    interrupted 


Fig.  44. — Method  of  Probing  the  Tube. 

sutures  of  fine  silk  threaded  on  the  smallest  needle,  the  peritoneal 
surface  of  the  tube  is  sutured  to  its  mucosa  at  a  number  of  differ- 
ent points.  In  this  way  we  can  be  fairly  certain  that  the  tube  will 
remain  patent.  In  several  cases  where  a  tube  has  been  obliterated 
in  its  middle  third,  I  have  removed  the  closed  section  and  then 
anastomosed  the  ends  of  the  tube  over  a  strand  of  kangaroo 
tendon  laid  in  the  lumen;  in  this  way  hoping  to  keep  the  tube 
patent  while  the  anastomosis  was  healing.  I  have  never  been  able 
to  trace  a  case  of  subsequent  conception  following  this  operation, 
although  there  are  several  instances  reported  in  the  literature. 


CHAPTER  XXIV 

THERAPEUTIC  ABORTION  AND  STERILIZATION 

Therapeutic  abortion — Therapeutic  sterilization — Case  history. 

Therapeutic  Abortion. — Where  the  life  of  both  mother  and 
child  are  in  danger  and  it  appears  quite  certain  that  only  one  can 
be  saved,  the  preference  should  be  given  to  the  mother,  as  her 
life  can  reasonably  be  said  to  be  of  greater  value  to  the  State  than 
that  of  her  unborn  child.  Where  certain  diseases  or  complications 
appear  during  the  course  of  pregnancy  that  threaten  the  life  of 
the  mother  should  the  pregnancy  continue,  the  consensus  of 
opinion  permits  and  even  calls  for  the  destruction  of  the  fetus. 
When  such  a  condition  arises  before  the  child  is  viable  it  is 
designated  as  prophylactic  or  therapeutic  abortion  and  is  a  justi- 
fiable procedure  in  the  presence  of  such  serious  conditions  as 
hyperemesis  gravidarum,  and  eclampsia,  vi^hich  do  not  yield  to 
treatment.  The  operation  is  always  justifiable  in  certain  cases 
of  pulmonary  tuberculosis,  cardiac  disease,  nephritis,  insanity,  and 
in  displacements  of  the  uterus  which  cannot  be  corrected.  In 
extreme  cases  of  pelvic  contraction  where  the  patient  refuses 
cesarean  section,  abortion  may  be  justifiable.  The  results  in  thera- 
peutic abortion,  when  carried  out  with  the  same  degree  of  skill 
and  care  as  any  other  surgical  operation,  are  good. 

Therapeutic  Sterilization. — Sterilization  is  often  carried  out 
as  a  therapeutic  measure  in  cesarean  section  when  the  operation 
is  performed  on  account  of  disproportion  incident  to  contracted 
pelves.  At  such  times  the  methods  usually  employed  to  prevent 
further  child  bearing  are  removal  of  the  ovaries,  removal  of  the 
uterus,  and  removal  of  the  tubes  in  part  or  in  whole.  Simple 
ligation  of  the  tubes  without  section  is  no  longer  trusted. 

Since  the  importance  of  the  internal  secretory  function  of  the 
ovaries  has  become  established,  their  removal  to  produce  sterility 
has  been  abandoned.    When  cesarean  section  was  performed  the 

199 


200  STERILITY  AND   CONCEPTION 

removal  of  the  uterus,  either  in  whole  or  in  part,  was  one  of  the 
earliest  means  employed  to  produce  sterility.  Porro's  operation, 
and  later,  supracervical  amputation  of  the  fundus  enjoyed  exten- 
sive popularity  in  this  connection.  These  are  now  largely  super- 
seded by  other  methods  and  because  of  their  unjustifiable  surgical 
risk  rarely,  if  ever,  used  for  the  sole  purpose  of  preventing  future 
pregnancy. 

Therapeutic  sterilization  is  at  the  present  time  practically 
limited  to  some  means  of  obliterating  the  lumen  of  the  oviducts. 
This  operation  was  first  performed  by  Lungren  in  1880,  who 
ligated  both  tubes  near  the  uterus,  following  a  cesarean  section. 
Many  failures  followed  this  simple  technic,  and  as  time  went  on 
resection  of  a  portion  of  the  tube  was  added.  This  was  not  always 
found  to  be  effectual,  and  many  cases  of  pregnancy  following  even 
the  entire  removal  of  both  tubes  were  reported. 

The  question  of  therapeutic  sterilization  is  brought  forward 
primarily  in  women  liable  to  become  pregnant  and  who  suffer 
from  some  organic  lesion  which  would  render  pregnancy  danger- 
ous to  their  future  life  or  health. 

Heart  lesions,  nephritis,  diabetes,  tuberculosis,  insanity,  and 
epilepsy  are  frequent  indications  to  which  should  be  added 
inability  to  bear  a  child  by  the  natural  way.  It  is  in  the  latter 
class  of  patients  that  therapeutic  sterilization  is  probably  most 
often  performed,  and  with  many  operators  it  has  been  a  matter  of 
pretty  general  routine  after  a  second  successful  cesarean  section. 
However,  the  danger  from  repeated  sections  has  been  so  min- 
imized that  it  is  now  no  greater  than  the  primary  operation,  and 
it  seems  to  me  that  the  decision  rnight  well  be  left  to  the  patient. 
Of  course,  when  some  contra-indication  to  future  pregnancy 
exists,  it  becomes  the  duty  of  the  operator  to  advise  the  steriliza- 
tion, and  if  during  a  cesarean  section,  conditions  arise  or  are  dis- 
covered that  would  prohibit  further  pregnancies,  he  should  be 
provided  with  the  necessary  authority  to  perform  it.  I  believe 
that  the  same  rule  should  hold  in  all  abdomino-pelvic  operations 
on  women.  The  repeated  bearing  of  mentally  deficient  children 
should  constitute  a  sufficient  indication  for  therapeutic  steriliza- 
tion. 

When  repeated  childbearing  so  wieakens  a  mother  as  to  pre- 
vent her  giving  the  necessary  care  to  the  children  she  already  has, 
then  I  believe  the  indications  for  therapeutic  sterilization  should 


THERAPEUTIC  ABORTION  AND  STERILIZATION  aoi 

be  broadened  to  include  her.  With  the  birth  of  each  child,  the 
woman's  life  becomes  an  increasingly  more  valuable  one  and 
should  receive  every  protection  from  the  State.  We  know  that 
for  many  women  further  pregnancies  are  simply  out  of  the  ques- 
tion. With  such  it  is  but  foolish  to  advise  continence,  for  married 
life  without  intercourse  is  hardly  to  be  realized;  contraceptives 
are  harmful,  uncertain,  or  both ;  and  repeated  abortion  offers  no 
solution.  The  only  safe,  effectual,  and  sane  methods  of  prevent- 
ing pregnancy  are  by  obliterating  the  fallopian  tubes  in  the 
woman  or  by  ligating  the  seminal  vesicles  in  the  man.  This  latter 
simple  operation  for  the  creation  of  neuters  is  to  be  recommended, 
but  does  not  seem  so  far  to  have  received  the  serious  attention  it 
really  deserves. 

Of  the  various  methods  of  sterilization  described  and  practiced 
tubal  resection  in  part  or  in  whole  is  the  one  most  generally 
employed.  This  is  safe  and  certain,  but  attended  with  the  dis- 
advantage that  the  sterility  is  absolute  and  cannot  be  relieved 
subsequently  should  the  occasion  arise.  Possibly  this  objection  is 
more  fancied  than  real,  yet  it  deserves  consideration,  for  an  occa- 
sional case  is  met  with  when  the  indications  that  prompted  the 
original  sterilization  no  longer  exist  and  further  children  are 
desired.  Likewise,  there  are  women  whose  mental  condition  is 
better  after  sterilization  if  they  can  be  promised  a  reasonable  hope 
of  having  the  sterility  relieved  at  some  future  time,  even  though 
there  be  but  a  slight  chance  of  this  ever  being  permissible. 

These  facts  suggest  the  advisability  of  temporar)'  sterilization 
in  certain  cases  and  led  me  a  number  of  years  ago  to  devise  a 
technic  that  I  thought  would  accomplish  the  purpose. 

The  fimbriated  end  of  each  tube  was  buried  in  a  pocket  made 
for  it  between  the  folds  of  the  broad  ligaments  and  from  which  it 
could  be  subsequently  released  in  practically  normal  condition  if 
the  occasion  should  arise.  Turenne  conceived  the  same  idea 
independently  and  performed  his  first  operation  in  October,  1916, 
three  years  after  mine.  Our  methods  of  procedure  were  prac- 
tically identical  with  one  exception — he  buried  the  tubal  ends  on 
the  posterior  face  of  the  broad  ligament,  while  I  buried  them  on 
the  anterior  face,  leaving  the  barrier  of  the  broad  ligament 
between  the  ovary  and  the  site  of  burial,  so  that  if  by  any  chance 
an  error  in  technic  should  leave  a  small  opening  from  the  peri- 
toneal cavity  to  the  lumen  of  the   tube,   there  would  be  little 


202  STERILITY  AND  CONCEPTION 

liability  of  an  ovum  going  over  the  top  of  the  broad  ligament  and 
finding  its  way  into  such  a  small  and  remote  opening.  How  griev- 
ously I  failed  in  estimating  the  powers  of  Nature,  the  subsequent 
history  of  my  case  well  illustrates.  Because  of  its  intense  interest, 
I  give  the  details  in  full  as  already  reported  elsewhere : 

Mrs.  L.  J.  W.,  age  thirty-two  years,  married  eleven  years,  during  which  time 
she  had  given  birth  to  three  full-term  children  by  instrumental  deliveries,  and  had 
had  two  miscarriages  at  five  weeks,  cause  unknown.  She  presented  a  lacerated 
and  greatly  relaxed  outlet  with  a  well-developed  rectocele.  The  cervix  was  lacer- 
ated and  hypertrophied,  the  uterus  freely  movable  in  normal  position.   - 

At  operation  on  November  15,  1913,  the  cervix  was  dilated  and  the  uterus 
curetted.  A  bilateral  trachelorrhaphy  and  perineorrhapy  were  performed.  The 
abdomen  was  then  opened  by  a  transverse  suprapubic  incision.  The  left  ovary, 
enlarged,  cystic,  and  prolapsed,  was  resected.  The  right  ovary  and  both  tubes 
were  normal. 

The  patient  had  requested  sterilization,  which  seemed  justifiable  in  view  of 
the  three  instrumental  deliveries  for  pelvic  contraction.  This  was  performed  by 
embedding  the  fimbriated  ends  of  each  tube  in  a  separate  pocket  on  the  anterior 
face  of  the  broad  ligament  and  holding  it  in  place  by  a  continuous  encircling  suture 
of  fine  silk.     Convalescence  was  uneventful. 

Normal  marital  relations  were  resumed  and  continued  until  January,  1916, 
when  she  menstruated  normally  on  January  17.  The  February'  and  March  periods 
were  missed,  and  when  I  examined  her  on  March  9,  the  uterus  showed  enlarge- 
ment and  softening.  There  had  been  marked  nausea  and  vomiting  during  the 
preceding  month  with  beginning  pains  in  the  breasts.  A  diagosis  of  pregnancy 
was  made,  and  on  March  11  the  abdomen  was  opened  through  the  scar  of  the 
old  incision.  A  transverse  fundal  incision  was  then  made  in  the  uterus,  and  an 
early  pregnancy,  with  numerous  old  and  fresh  blood  clots,  removed.  In  this  no 
fetus  was  discovered,  but  the  pathological  report  returned  from  the  laboratory 
reported  pregnancy.  The  uterine  incision  was  closed  and  the  proximal  ends  of 
the  tubes  tied  with  linen  sutures  and  cut,  in  order  to  make  certain  the  sterilization 
attempted  at  the  first  operation  three  years  before. 

At  this  time  I  carefully  examined  the  site  of  the  embedding  of  both  tubes. 
On  the  right  side  there  was  continuous  union  between  the  broad  ligament  and  the 
circumference  of  the  tube,  and  at  no  point  could  I  discover  any  point  of  com- 
munication between  the  peritoneal  cavity  and  the  embedded  ostium  of  the  tube. 
On  the  left  side  the  embedding  was  equally  perfect  with  the  exception  of  just  one 
point  anteriorly,  where  a  minute  opening,  pin  point  in  size,  was  seen.  W^ith  a  little 
force  this  opening  admitted  the  passage  of  the  smallest-sized  filiform  bougie. 
Here,  then,  was  the  communication  between  the  abdominal  cavity  and  the  ostium 
of  the  tube,  through  which  the  ovum  had  passed.  Nature  had  proved  herself  equal 
to  the  emergency.  The  ovum  had  migrated  to  the  anterior  face  of  the  broad 
ligament  and  entered  the  embedded  ostium  of  the  tube  through  the  opening 
described,  which  was  so  minute  as  to  be  hardly  perceptible  to  the  naked  eye. 

With  further  experience  in  therapeutic  sterilization  I  have 
devised  what  I  think  to  be  a  surer  and  better  way  of  accomplish- 
ing temporary  sterilization,  which  is  to  invert  the  fimbriae  into  the 
tube  and  close  the  lumen  with  purse-string  sutures.  The  operative 
technic  for  this  method  of  closure  is  as  follows : 


THERAPEUTIC  ABORTION  AND  STERILIZATION 


203 


Two  purse-string  sutures  of  small-size  chromic  catgut  are 
passed  around  the  tube  one-half  inch  apart  a  short  distance  back 
from  the  fimbriae,  which  are  then  inverted  into  the  lumen  of  the 
tube,  and  the  sutures  drawn  tight  and  tied.  The  site  of  closure  is 
then  touched  with  tincture  of  iodin  in  order  to  set  up  a  chemical 
peritonitis  at  this  point  so  as  to  make  the  permanent  closure  of 
the  tube  more  certain.  By  this  means  we  have  a  method  that 
closely  approximates  the  way  Nature  seals  of¥  the  tubes  in  gonor- 
rhea— one  certainly  effective — and  one  that  offers  a  reasonable 
hope  of  being  able  to  relieve  the  sterility  in  the  future  should  the 


Fig.  45. — Therapeutic  Sterilization;  Author's  Tubal  Closure. 


occasion  arise.     This  technic  I  have  carried  out  in  three  cases  so 
far  without  failure. 

LITERATURE 


Blumberg.    Berlin.  Klin.  Woch.     19 13. 
Blundell.     Medico  Chi.  Trans.    London,  1819. 
Child,  Jr.    Surg.,  Gyn.  and  Obstet.    March,  1920. 
De  Tarnowsky.    J.  A.  M.  A.     1913. 
Fraenkel.    Arch.  f.  Gynak.     1899. 
HoLZAPFEL.     Zeitsch.  f.  Geb.  u.    Gyn.     Vol.  LXXIX. 
LuNGREN.    Am.  Journ.  Obst.     1881. 
Nurnberger.     Sammlungklin.  Vortrage,  nf.     1917. 
Taussig,  F.  J.    Surg.,  Gyn.  and  Obstet.     1906. 
Turenne.     Surg.,  Gyn.,  and  Obstet.     Dec,  1919. 
Williams.     The  Am.  Journ.  Obst.  and  Gyn.     1921. 
Zweifel.    Arch.  f.  Gynak.     1899. 


CHAPTER  XXV 

COMBINED  THERAPEUTIC  ABORTION  AND 
STERILIZATION 

Case  histories — Operative  tephnic — Conclusions. 

Combined  Therapeutic  Abortion  and  Sterilization. — This 
operation  is  recommended  for  patients  suffering  from  serious 
organic  disease  where  a  continuation  of  the  pregnancy  would  be 
a  serious  menace  to  their  Hfe,  and  with  whom  the  same  indication 
for  the  interruption  would  arise  in  future  pregnancies. 

Of  first  importance  are  the  cases  with  serious  heart  lesions, 
notably  mitral  stenosis,  that  are  prone  to  attacks  of  decompensa- 
tion during  pregnancy,  or  who  have  had  attacks  of  decompensation 
at  other  times.  Next  in  importance  come  the  cases  of  tuberculosis, 
nephritis,  insanity,  and  epilepsy. 

Sellheim  in  1913  was  the  first  to  advocate  the  operation  of 
simuhaneous  abdominal  abortion  and  steriHzation.  He  reported 
several  cases,  using  in  them  all  a  median-line  abdominal  incision 
and  a  transverse  fundal  incision  in  the  uterus  from  tube  to  tube. 
Through  this  incision  the  gestation  was  removed,  and  then  one- 
half  inch  of  each  tube  was  cut  away,  the  tube  then  being  ligated 
and  dropped  back  between  the  folds  of  the  broad  ligament. 

Hoffman  in  1914  reported  twenty  cases,  but  used  a  median 
incision  in  both  abdomen  and  uterus.  In  19 14  I  reported  a  case  in 
which  the  technic  of  the  operation  was  further  improved  by 
making  a  transverse  abdominal  incision.  Findley,  the  following 
year,  reported  four  cases  using  this  method. 

The  technic  of  this  operation  for  simultaneous  abortion  and 
sterilization  is  as  follows: 

A  transverse  suprapubic  incision  two  and  one-half  to  three 
inches  in  length  is  made  three  finger  breadths  above  the  symphysis 
pubis.  Through  this  the  fundus  is  exposed  to  view,  grasped  at 
each  horn  with  a  pair  of  traction  forceps  and  drawn  up  into  the 

204 


THERAPEUTIC  ABORTION  AND   STERILIZATION 


205 


wound.  One  ampule  of  pituitrin  is  now  given  and  its  action 
awaited.  In  a  very  short  space  of  time,  usually  from  twenty  to 
sixty  seconds,  blanched  areas  appear  on  the  surface  of  the  uterus 


Fig.  46. — ^Jackson's  Tenaculum  Forceps. 

and  contractions  become  quite  noticeable.  An  incision  opening 
into  the  uterine  cavity  is  now  made  across  the  fundus  from  horn 
to  horn.     By  this  time  the  uterus  is  contracting  so  strongly  that 


iir^*T"*. 


Courtesy  of  Lippincott. 

Fig.  47. — Decidual  Abortion  (Shears). 

as  soon  as  the  cavity  is  opened  the  ovum  is  partly  extruded.  If 
the  operation  is  performed  within  the  first  two  months  after  con- 
ception, the  ovum  can  readily  be  delivered  intact.     At  this  period 


2o6  STERILITY  AND  CONCEPTION 

of  pregnancy  the  decidua  constitutes  the  great  bulk  of  the  ovum 
and  to  these  cases  the  term  "decidual  abortion"  suggested  by 
Shears  is  particularly  applicable.  After  about  two  and  one-half 
months  the  placental  formation  is  complete ;  the  placenta  then 
forms  the  greater  bulk  of  the  ovum,  and  uterine  attachment  is 
more  secure,  so  that  care  is  necessary  to  complete  its  removal. 
The  finger  introduced  into  the  uterine  cavity  separates  the  ovum, 
which  is  then  easily  removed  with  the  aid  of  a  sponge  holder. 
The  whole  process  of  emptying  the  uterus  in  this  way  is  aston- 
ishingly quick  and  free  from  hemorrhage.  It  is  not,  as  a  rule, 
necessary  to  pack  or  drain  the  uterine  cavity.  After  passing  sev- 
eral interrupted  catgut  sutures  through  the  muscular  walls  of  the 
uterus  to  close  the  uterine  cavity  and  to  control  any  bleeding,  the 
sterilization  is  proceeded  with.  This  is  accomplished  by  severing 
the  tubes  at  their  cornua,  ligating  the  cut  ends  with  linen  or  silk, 
and  pushing  them  down  between  the  two  layers  of  the  broad  liga- 
ments on  either  side  of  the  uterus.  A  continuous  suture  of  small- 
size  catgut  now  closes  the  peritoneal  covering  of  the  uterus  and  is 
so  tied  at  either  end  as  to  prevent  releasement  of  the  buried  tubal 
ends.  Closure  of  the  abdominal  incision  completes  the  operation. 
The  following  cases  are  given  as  illustrative  of  some  of  the 
more  urgent  indications  for  the  operation : 

Mrs.  A.  B.,  thirty-three  years  old,  had  been  married  for  eighteen  years  and 
during  that  time  had  given  birth  by  prolonged  labors  to  four  children,  the  last 
eight  years  ago.  With  each  delivery  she  suffered  from  marked  cardiac  involvement 
that  became  progressively  more  serious,  and  with  the  last  she  had  a  well-developed 
attack  of  decompensation.  Since  then  three  abortions  have  been  induced  at  six 
weeks,  the  last  two  and  one-half  years  ago,  as  her  physician  felt  that  pregnancy 
was  a  distinct  menace  to  her  life.  She  is  now  between  three  and  one-half  and  four 
months  pregnant  and  has  a  mitral  stenosis  with  breaking  compensation. 

On  operation  at  the  Polyclinic  Hospital,  March  14,  1914,  a  transverse  supra- 
pubic incision  was  made,  the  gestation  removed,  and  sterilization  accomplished 
through  a  transverse  fundal  incision,  the  uterine  cavity  being  packed.  The  maxi- 
mum temperature  after  operation  was  101.2  with  a  pulse  of  102  on  the  first  day. 
This  became  normal  with  a  pulse  of  98  on  the  second  day,  and  the  wound  healed  by 
primary  union.  The  uterine  packing  was  removed  on  the  third  day,  and  the  patient 
allowed  out  of  bed  on  the  seventh  day. 

Mrs.  S.  W.,  thirty-five  years  old,  married  fourteen  years.  She  has  had  three 
full-term  children,  all  with  prolonged  labors  terminated  by  difficult  instrumental 
deliveries,  and  two  abortions  at  five  weeks.  The  childbirth  traumatism  to  cervix 
and  perineum  had  been  repaired  three  years  ago,  and  sterilization  attempted  by 
embedding  the  tubal  ends.  She  missed  two  menstrual  periods  with  marked  nausea 
and  vomiting  for  the  past  month. 


THERAPEUTIC  ABORTION  AND   STERILIZATION 


207 


Examination  showed  the  uterus  to  be  soft  at  the  fundus  and  enlarged  to  cor- 
respond with  the  period  of  amenorrhea.  At  operation  in  the  Polyclinic  Hospital 
on  March  11,  1916,  through  a  transverse  abdominal  and  fundal  incision  the  gesta- 
tion was  removed  and  the  tubes  cut,  ligated,  and  buried  as  described  above.  Con- 
valescence was  uneventful.  The  maximum  postoperative  temperature  recorded  was 
100,  with  a  pulse  of  90  on  the  day  of  operation,  which  became  normal  with  a  pulse 
of  89  on  the  first  day  after.     The  wound  healed  by  primary  union. 

Mrs.  R.  K.,  twenty-seven  years  old,  had  been  married  nine  years,  having  given 
birth  to  three  children,  the  last  two  years  ago.  She  is  now  pregnant  for  the  fourth 
time,  the  period  of  gestation  being  about  two  months.  She  has  pulmonary  tuber- 
culosis and  epilepsy. 


Fig.  48. — Author's  Simultaneous  Abdominal  Abortion  and  Sterilization  Showing: 
Incision  through  Abdominal  Wall  and  Fundus  of  the  Uterus. 

At  operation  in  the  Polyclinic  Hospital  on  February  7,  1918,  the  uterus  was 
exposed  by  a  transverse  suprapubic  incision,  the  gestation  removed  intact  through 
a  transverse  fundal  incision,  the  tubes  cut,  ligated,  ends  buried  and  the  incision 
closed.  Convalescence  was  uneventful;  the  highest  temperature  reached  was  101.2 
with  a  pulse  of  72  on  the  evening  of  the  day  of  operation,  which  dropped  to  normal 
with  a  pulse  of  74  on  the  fifth  day.     Wound  union  was  by  primary  intention. 


Mrs.  D.  R.,  thirty-two  years  of  age,  had  been  married  twelve  years,  during 
which  time  she  has  had  two  children  and  no  miscarriages.  Shortly  after  her  first 
labor  she  developed  leprosy.  The  disease  progressed  slowly  until  the  next  preg- 
nancy, during  which  its  progress  was  more  rapid,  but  abated  somewhat  after 
delivery.  She  is  now  about  four  months  pregnant,  and  the  leprous  sympioms  have 
again  become  active.  After  consultation  with  her  attending  dermatologists  it  was 
decided  to  interrupt  the  pregnancy.     Accordingly,  on  April  7,   1921,  at  the  City 


2o8 


STERILITY  AND  CONCEPTION 


Hospital  a  therapeutic  simultaneous  abortion  and  sterilization  was  performed  by 
the  abdominal  route,  transverse  suprapubic  incision,  transverse  fundal  incision, 
with  ligation  and  embedding  of  the  proximal  tubal  ends.  Convalescence  was 
uneventful,  the  patient  running  a  maximum  temperature  of  100.4  on  the  second 
day  after  the  operation,  with  a  pulse  of  108.  On  the  fourth  day  the  temperature 
became  normal,  the  pulse  108,  and  the  wound  healed  by  primary  union. 

Operative  Technic. — The  transverse  abdominal  incision  has  in 
general,  many  advantages  over  the  median-line  incision  which  I 
have  taken  up  fully  elsewhere  and  will  not  dilate  on  again  here. 
For  the  operation  under  discussion  it  is  particularly  well  adapted. 


Fig.  49. — Author's  Simultaneous  Abdomin.\l  Abortion  and  Sterilization  Showing 
A.,  continuous  closing  sutvu-e  in  uterine  wall  cover.  B.,  deep  approximating 
sutures. 

allowing  as  it  does  the  fundus  to  be  drawn  tightly  into  the  field 
of  operation,  thus  blocking  off  the  free  peritoneal  cavity  and 
making  the  emptying  of  the  uterus  and  the  sterilization  practically 
extraperitoneal.  Both  the  abdominal  and  uterine  incisions  lie  in 
the  same  line,  thus  giving  a  maximum  exposure  of  the  uterus  with 
a  minimum  exposure  of  the  rest  of  the  abdominal  contents. 

The  actual  emptying  of  the  uterus  is  accomplished  with  far 
greater  celerity  and  ease  through  the  transverse  fundal  incision, 
and  additional  incisions  are  not  required  for  the  sterilization. 
There  is  also  much  less  bleeding  than  when  a  median  incision  in 
the  uterus  is  used.  The  reaction  following  the  operation  is  slight; 
the  four  cases  reported  above  showed  an  average  elevation  of 


THERAPEUTIC  ABORTION  AND  STERILIZATION 


209 


temperature  of  only  2.3  degrees  and  an  average  increase  in  pulse 
rate  of  only  13  beats  to  the  minute,  which  occurred  on  the  second 
day.     The  temperature  dropped  to  normal  on  the  third  day. 

In  support  of  simultaneous  abdominal  abortion  and  steriliza- 
tion, I  would  urge  that  it  is  quick,  complete  and  certain.  It  is 
attended  by  far  less  risk  to  the  patient  than  is  the  combined 
vaginal  and  abdominal  operation.  It  should  only  be  done  in  clean 
cases,  however,  where  there  has  been  no  attempt  at  interference 
from  below.  It  is  not  applicable  to  cases  where  even  a  short 
anesthesia  would  be  contra-indicated;  in  these  the  more  con- 
servative treatment  of  emptying  the  uterus  from  below  and 
reserving  the  sterilization  for  some  future  time  is  to  be  preferred. 


Fig.  50. — Author's  Simultaneous  Abdominal  Abortion  and  Sterilization  Showing 
Treatment  of  the  Tubes  and  Closure  of  the  Uterine  Incision.  A.,  con- 
tinuous chromic  catgut  suture.     B.,  tube  cut  and  ligated.     C,  tubal  end  buried. 

but  only  too  often  when  the  sterilization  is  postponed  another 
pregnancy  intervenes  before  it  is  accomplished,  and  such  cases  not 
infrequently  result  disastrously. 


CONCLUSION 

What  advice  should  be  given  in  cases  of  sterility?  This  is 
probably  the  most  difficult  question  of  all  to  decide.  When  all 
examinations  have  been  made  and  we  take  up  for  final  review 
the  recorded  facts  in  an  individual  case,  a  more  or  less  definite 
cause  for  the  sterility  can  usually  be  settled  upon.  The  treatment 
for  this  may  be  simple  and  free  from  danger,  or  it  may  be  complex 
and  call  for  operative  measures,  the  carrying  out  of  which  would 
be  attended  by  a  very  definite  surgical  risk.     In  such  cases  do  the 


210  STERILITY  AND   CONCEPTION 

danger  and  uncertainty  of  result  warrant  the  surgeon  in  advising 
such  a  risk,  or  the  patient  in  accepting  it?  In  deciding  such  a 
question  we  have  no  precedent  in  surgery  to  go  by,  for  from  time 
immemorial  surgical  operations  have  only  befen  advised  to  save 
life  or  to  relieve  suffering,  where  the  ethical  ground  has  always 
been  firm  under  our  feet.  Now  we  are  facing  an  entirely  new 
situation.  Our  position  rests  on  no  such  firm  foundation  of  fixed 
opinion,  but  rather  on  the  uncertain  and  ever-shifting  quicksands 
of  controversial  opinion,  which  is  a  very  different  matter.  If  the 
assumption  of  a  major  operative  risk  is  justifiable  in  the  hope  of 
relieving  suffering  or  of  saving  a  life,  is  it  then  also  justifiable  in 
the  hope  of  creating  a  new  life?  If  not,  then  just  how  much  risk 
are  we  warranted  in  taking  in  our  efforts  to  relieve  sterility?  To 
be  sure  the  question  is  much  simplified  in  the  presence  of  marked 
pathological  lesions  which  in  themselves  are  responsible  for  a 
certain  degree  of  ill  health  or  suffering,  independent  of  the 
coexisting  sterility,  and  which  call  imperatively  for  surgical  relief. 
But  this  is  only  begging  the  question  and  helps  not  at  all  in  decid- 
ing what  is  justifiable  in  the  presence  of  the  single  uncomplicated 
symptom  of  sterility.  I  can  see  but  one  course  that  is  fair  and 
ethical,  and  that  is  to  leave  the  ultimate  decision  to  the  parties 
most  concerned.  The  husband  and  wife  must  make  the  final 
decision. 

In  bringing  this  clinical  study  of  sterility  to  a  close  it  is  with 
the  most  sincere  regret  that  I  have  not  been  able  to  present  any- 
thing like  a  complete  record  of  all  cases  of  sterility  treated,  and  of 
the  many  relieved.  Lack  of  space  has  prevented  the  former 
while  the  many  difficulties  of  carrying  out  an  adequate  follow-up 
system  have  made  the  latter  impossible.  Though  small  in  num- 
ber, the  cases  cited  have  been  carefully  studied  and  followed  up, 
and  I  feel  serve  fairly  well  as  illustrative  examples  of  what  it  is 
possible  to  accomplish  in  the  surgical  relief  of  sterility. 

I  am  well  aware  that  many  unsuccessful  operations  have  been 
performed  in  the  past,  just  as  many  will  be  performed  in  the 
future.  This  must  of  necessity  be  so  in  sterility  as  well  as  in  many 
other  conditions,  but  as  the  subject  is  more  thoroughly  studied 
the  results  will  improve  and  much  uncertainty  will  later  yield  to 
certainty.  Reproduction  is  of  paramount  importance  to  the  race 
and  is  a  subject  worthy  of  the  most  careful  and  faithful  study. 
Every  case  of  absolute  sterility  cured  by  operative  measures — and 


THERAPEUTIC  ABORTION  AND  STERILIZATION  211 

they  can  be  cured  in  no  other  way — is  a  triumph  for  gynecology. 
Where  the  result  is  the  birth  of  a  living  child  and  the  fruit  of  the 
surgeon's  work  is  carried  on  to  generations  yet  unborn,  then 
indeed  is  the  triumph  great.  Surely  it  would  be  difficult  for  any 
other  department  of  surgery  to  confer  a  higher  reward  on  the 
operator  or  to  show  results  of  greater  value  to  society.  It  is  such 
results  as  these  that  should  go  far  towards  creating  in  the  sur- 
geon an  added  respect  for  the  art  he  practices  and  a  firmer  belief 
in  the  value  of  conservative  gynecology. 


LITERATURE 

Child,  Jr.,  C.  G.     Trans.  N.  Y.  Obstet.  Soc.     Nov.,  1914, 
FiNDLEY,  P.    Am.  Journ.  Obs.  and  Gyn.     191 5. 
Hoffman.    Zeitschr.  f.  Geb.  u.  Gyn.,  Bd.  75,  H.  2. 
Sellheim.    Monatschr.  f.  Geb.  u.  Gyn.,  Bd,  38,  H.  2. 
Shears,  G.  P.    Obstetrics.     1916. 


INDEX 


Abdominal  incision,  operative  technic  of, 
i8i 

author's  modification  of  Pfannen- 

stiel  incision,   183 

advantages  of,  184 

closure  of  incision,  188 

Kiistner-Rapin  incision,  182 

: Pfannenstiel  incision,  182 

Abortion,  in  anteflexion  of  uterus,  97 

—  common-law^    interpretations    of,    153 

—  criminal,    154 

—  habitual,  due  to  retrodisplacements  of 

uterus,  115 
and  relative  sterility,  95 

—  therapeutic,  indications  for,  199 
and  therapeutic  sterilization,  com- 
bined, indications  for,  204 

cases  illustrating,  206 

technic  of,  204 

author's,  208 

Adnexa,   enlargement  of,  treatment  of, 

59 
Age,  as  factor  in  fibroids  of  uterus,  126 

—  as  influencing  fertility,  39,  48 

—  of  marriage,  influence  of,  on  fertility 

and  sterility,  54 
Alcoholism,  influence  of,  on  fertility,  53 
Amenorrhea,    due    to    climatic    changes, 

48 
Anatomical  errors,  as  cause  of  sterility, 

44 
Anorchism,  causing  sterility  in  male,  63 
Anteflexion   of  uterus,   abortion   gener- 
ally succeeding  pregnancy  in,  97 

—  associated  with  sterility,  97 

—  degrees   of,  97 

—  examination  and  treatment  under  an- 

esthesia, 99 

—  mutilating  operations  for,  98 

—  second  pregnancy  often  successful  in, 

98 

—  significance  of,  97 

—  treatment  of,  under  anesthesia,  99 
faulty  surgery,  ICO 

—  —  proper  development  of  uterus,  98 
Antenatal  death.  See  Fetal  Mortality 
Antisyphilitic   treatment   of   prospective 

mothers,  50 


Aspermia,  62 

—  causes  of,  62 

—  diseases  causing,  62 

—  partial  or  complete,  62 

—  temporary  or  permanent,  62 
Azoospermia,  62 

Bartholin's  glands,   description  and  po- 
sition of,  ^^,  84 

—  gonorrheal  infection  of,  ']^ 

—  inflammatory  infection  of,  84 

—  secretion  of,  in  sexual  excitement,  'JT, 

84 
Birth    control,    arguments   advanced   by 

advocates  of,  146 
— ■  and  eugenics,  8 

—  and  modern  civilization,  3 

—  organized,  13 

—  and  overpopulation,  148 

—  propaganda  on,  13 

—  —  injurious  effect  of  repeated  child- 

bearing  to  woman,  54 

—  as  a  therapeutic  measure,  8 
Bladder,  and  fundus,  102 
Breeding,  and  seasonal  influence,  2>7 
Breeding  seasons  in  animals,  36 

Cervical  amputation,  technic  of,  178 
Cervical  lacerations,  cervical  repair  for, 

technic  of,  174 
Cervical  repair,  technic  of,  174 
Cervical  smears,  to  determine  presence 

or  absence  of  spermatozoa,  58 
Cervical  stenosis,  treatment  of,  100 
Cervicitis,  chronic,  case  reported,  90 

description  of,  89 

infecting  organisms  of,  89 

and  lacerations  of  cervix,  93 

process  of,  89 

— ■  —  result  of,  92 

treatment  of,  medical,  90 

operative,  91 

Cervix,  dilatation  of,  technic  of,  169 

—  extensively  infected,  amputation  for, 

92 

—  and   fundus,    103 

—  gonorrheal  infection  of,  ^^ 


213 


214 


INDEX 


Cervix,  lacerations  of,  92 

case  reported,  92 

causing  sterility,  93 

relative,  and  habitual  abortions, 

95 

and  chronic  cervicitis,  93 

repair  of,  59 

treatment  of,  95 

Child,  era  of,  14 

Childbirth,  accidents  of,  160 

Chorion  ferments,  role  of,  in  protection 
of  fetus  in-utero,  50 

Civilization,  modern,  effect  of,  on  re- 
productivity,  3 

Climatic  changes,  as  influencing  fertility 
and  sterility,  48 

Co-education,  4 

Coitus,   excessive,   affecting   fertility,  48 

—  hindering  of,  by  vaginismus,  44,  82 

—  painful,  or  dyspareunia,  44 

—  —  due  to  urethral  caruncles,  85 
due  to  vaginal  cysts,  85 

—  painful  and   later  impossible,   due  to 

kraurosis  vulva,  85 

—  prevention  of,  by  vaginismus,  44 

—  See  also  Intercourse 
Complement-fixation    test,    in    diagnosis 

of  gonorrhea,  76 
Conception,  malignant  tumors  of  uterus 
barrier  to,  52 

—  prevention,  practice  of,   146 
Contraceptives,  consideration  of,  149 
Corpus   luteum,   endocrine   function   of, 

21 

—  large,  cystic,  associated  with  frequent 

and  profuse  menstruation,  case  ex- 
emplifying, 23 

—  and  menstruation,  23 

—  of  pregnancy,  23 

—  recognition  of,  21 

Creative   and  developmental   differences 

of  sex,  10 
Criminal  abortion,  154 
Cryptorchidism,  causing  sterility,  63 
Curettage,  technic  or,  173 

Dietary,  as  factor  in  fertility  and  steril- 
ity, 46,  73 
Dilatation  of  cervix,  technic  of,  169 
Divorce,  increase  in,  12 
Dyspareunia,  44 

—  as  cause  of  sterility,  65,  83 

—  causes  of,   in  disease  of  genital  or- 

gans, 84 

—  due  to  vaginal  cysts,  85 

—  transitory  nature  of,  83 

—  treatment  of,  86 


Dyspareunia  treatment,  by  enlarging  the 
introitus  vaginalis,  technic  of  opera- 
tion, 169 

Ectropion,  92 

Educated   classes,  and  reproductivity,  3 
Education,  and  idealization  of  mother- 
hood, 12 

—  importance    of,    in    reproduction    and 

sex  hygiene,  72,  73 
Education  in  sex  hygiene,  8,  72,  y^ 
Endocrine  function,  of  corpus  luteum,  21 
Endometritis,  causing  sterility,  50 
Enlarging    of    external    os,    technic    of, 

173 

Episiotomy,  median  of  lateral,  technic 
of,  169 

Estrus  cycle  of  lower  animals,  men- 
strual cycle  homologous  with,  25 

—  periods  of,  25 

Eugenics,  and  birth  control,  8 
External   os,    enlarging   of,    technic   of, 
173 

Fallopian  tubes,  determining  the  patency 

of,  by  direct  probing,  69 
by  intra-uterine  inflation  with  oxy- 
gen, Rubin's  technic,  69 
by  introducing   solutions   traceable 

by  roentgenography,  69 

—  gonorrheal  infection  of,  78 
Family,  average  size  of,  among  educated 

people,  7 

—  decay  of  parental  supervision,  12 

—  decrease,  9 

—  and  era  of  child,  14 

—  and  home  life,   14 

—  and  idealization  of  motherhood,  12 

—  lightening  the  burden  of,  by  legisla- 

tion, 5 
Fertility,  age  as  factor  in,  48 

—  age  of  {greatest,  39,  48 

—  decrease  of,  among  native  born,  5 

—  definition  of,  39 

—  dietary  as  a  factor  in,  46 

—  influence  on,  of  alcoholism,  parental,  53 
of     incompatibility,     physical     and 

mental,  55 

—  nutrition  as  factor  in,  46 

—  period  of,  in  men  and  women,  39 

—  and  race,  39 

—  relation    to,    of    fibroid    tumors    of 

uterus,  50 

—  spermatozoa,  quality,  57 
Fertilization,  early  ideas  of,  31 

—  essential  fact  of  (Wilson),  34 

—  and  ovulation,  25 


INDEX 


ai5 


Fertilization,  point  and  time  of,  28 

—  See  also  Reproduction,  methods  of 
Fertilizing   element,    in    the   male.      See 

Semen 
Fetal  deaths,  unavoidable,  160 
Fetal  mortality,  causes  of,  157 

—  causes  and  periods  of,  158 

—  due  to  syphilis,  49 

—  due.  to  toxemias  of  pregnancy,  156 
Fetus,  protection  of,  in  utero,  by  chorion 

ferments,  49,  50 

—  in    utero,    protection    of    by    chorion 

ferments,  49 
treatment    of    prospective    mother, 

anti-syphilitic,  50 
Fibroid  sterility,  126 
Fibroids    of    uterus,    and   accompanying 

retrodisplacements,  129 

—  affecting  fertility  and  sterility,  50 

—  age  as  factor  in,  126 

—  case   cited,    as   noteworthy   exception 

to  rule,  130 

—  conception  following  removal  of,  128 

—  diagnostic  errors  in,  129 

—  frequency  of,  51 

—  menstruation  in,  130 

—  multiple,  129 

—  myomectomy  for,  132 
operative  technic,  194 

—  occurrence  of,  1261 

—  as  result  of  sterility,  50 

—  and  sterility,  127 

Fibrosis,    uterine,    as    factor    in    dimin- 
ished fertility,  51 
Fission,  17 
Fundus,  and  bladder,  102 

—  and  cervix,  103 

Generative  organs,  in  lower  mammals, 
dormancy  of,  periodic,  26 

Genital  organs,  male,  fertilizing  element 
of,  semen,  60 

Germ  cell  retardation,  as  cause  of  ste- 
rility, 43 

Germ  cell,  female,  development  of,  cor- 
pus  luteum,  21 

—  endocrine     function    of     corpus 

luteum,  21 

• — ^  internal      secretion      of      corpus 

luteum,  21,  23 

ovaries,  21 

ovulation,  24 

and  fertilization,  25 

— ■  fertilized,  growth  of,  imbedding  of 
the  ovum,  33 

—  microscopy  of,  18 

—  Schultze's  definition  of,  20 


Germ,  sexual  attraction  between,  31 

—  union  of,  32 

Germ  plasm,  Weismann's  theory  of,   16 
Glands    of    Bartholin,    description    and 
position  of,  T],  84 

—  gonorrhea  infection  of,  ^^ 

—  inflammatory  infection  of,  84 

—  secretion  of,  in  sexual  excitement,  ^^t 

84 
Gonorrhea,  of  Bartholin's  glands,  ^^ 

—  causing  prematurity,  158 

—  causmg  sterility,  49,  75 

—  of  the  cervix,  ^^ 

—  chrpnicity  of,  ^^ 

—  diagnosis  of,  complement-fixation  test, 

76 

—  occurrence  and  frequency  of,  76,  ^^ 

—  of  the  ovaries,  78 

—  process  of  invasion  of  disease,  ^^ 

—  relative     gravity     of,     in     male    and 

female,  49 

—  of  Skene's  glands,  ^^ 

—  specific  cause  of,  76 

—  treatment  of,  79 

—  tubal  occlusion  due  to,  138 
cases  cited,  140,  141 

■ route  of  infection,  138 

—  of  urethra,  77 

■ —  of  the  uterus,  78 

—  of  vulva  or  vagina,  77 
Gonorrheal  menace,  statistics  of,  79 

Habitual  abortion,  due  to  retrodisplace- 
ments of  uterus,  115 

—  and  relative  sterility,  95 
Harvey's  aphorism,  16 
Hemorrhage,  causing  prematurity,  158 
Heredity,  in  process  of  reproduction,  35 
Home  life,  14 

Hygienic  measures,  in  treatment  of  ste- 
rility, 73 

Impotence,    organic,    in    male,    causing 
sterility,  62 

—  premature,  evil  effects  of,  64 

—  psychical,  63 
Impotentia  coeundi,  61 
Impotentia  generandi,  61 
Incisions,  abdominal,  technic  of,  181 
author's    modification    of    Pfan- 

nenstiel  incision,  183 

advantages  of,   184 

closure  of  incision,  188 

Kiistner-Rapin  incision,  182 

Pf annenstiel  incision,   182 

—  vaginal,  technic  of,  181 


2l6 


INDEX 


Incompatibility,  physical  and  mental,  in- 
fluencing fertility,  55 

Infant  mortality,  due  to  toxemias  of 
pregnancy,   156 

Infantile  pelvic  organs,  causing  sterility, 

45 
Infantile  uterus,   treatment  of,   to  cure 

sterility,  58 
Infantilism,  causing  sterility,  45 
Inflammatory  disease  of  genital  organs, 

as  cause  of  dyspareunia,  84 
Inflammatory  processes,  influence  of,  on 

sterility,  53 
Intercourse,  difficult,  due  to  constriction 

of  vagina,  44 

—  prevention  of,  by  stenosis  of  vagina, 

44 

—  See  also  Coitus 

Intra-uterine  inflation  with  oxygen,  to 
determine  the  patency  of  fallopian 
tubes,  Rubin's  technic,  69 

Introitus  vaginalis,  enlarging  of,  curet- 
tage, 173 

dilatation  of  cervix,  169 

for     dyspareunia     or     vaginismus, 

operative  technic,  169 

enlarging  of  external  os,  173 

Involution  of  uterus,  process  of,  134 

Kraurosis   vulva,   characteristics    of,   85 

—  rendering    coitus    painful    and    later 

impossible,  85 

—  treatment  of,  85 

Kiistner-Rapin  abdominal  incision,  tech- 
nic of,  182 

Laceration  of  cervix,  repair  of,  59 
Leucorrheal   discharge,   in   diagnosis  of 

sterility,  65 
Levator  ani  muscle,  106,  107 
Life,  origin  of.     See  Origin  of  Life 
Ligaments  of  the  uterus,  103 

—  broad  ligaments,  104 

—  cervico-vaginal  insertion,  105 

—  round,  105 

—  transverse  cervical,  105 

—  utero-sacral,  104 

Maldevelopment,  as  cause  of  sterility,  44 
Marriage,  age  of,  influence  on  fertility 
and  sterility,  54 

—  decrease  in,  12 

among  college  graduates,  3 

and  divorce,  12 

—  early,  advantages  of,  7Z 

—  late,  as  influence  in  sterility,  73 


Marital   unfruitfulness,   and   birth   con- 
trol, 3 

—  consideration  of,   i 

—  disadvantages  of,  i 

—  as    due    to    conditions   of    society   or 

mode  of  life,  2 

—  and  modern  civilization,  3 

—  See  also  Sterility 
Maternal  sense,  2 

Menstrual  cycle  in  woman,  homologous 
with  estrus  cycle  of  lower  mammals, 

25 
Menstruation,  and  corpus  Juteum,  22, 

—  in  diagnosis  of  sterility,  65 

—  in  fibroids  of  uterus,  130 

— -  frequent,     profuse,     associated     with 
large,  cystic  corpus  luteum,  23 
case  exemplifying,  23 

—  periodicity  of,  37 

—  and  pro-estrum  in  mammals,  25 

—  relationship  between  ovulation  and,  46 

—  and  sexual  season  in  animals,  37 

—  suspension      of,      due      to      climatic 

changes,  48 

—  influence  on,  of  internal  secretion  of 

ovaries,  23 
Middle  classes,  and  home  life,  14 

—  sterility  in,  7 
Mitotic  cell  division,  30 

Morals,     standard     of,     for     men     and 

women,  55 
Alotherhood,  idealization  of,  12 

—  instinct  of,  2 

—  subsidence  of  interest  in,  13,  14 
Myomectomy,  132 

—  technic  of,  194 

Non-impregnation,  causes  of,  61,  62 
Non-ovulating  ovary,   gross   and   histo- 
logical description  of,  122 
Nutrition,    as    factor    in    fertility    and 
sterility,  46 

Obesity,  as  factor  in  sterility,  7^ 

—  as   influencing    fertility   and   sterility, 
.46 

—  in     sterility,     rectal     examination     in 

diagnosis  of,  67 
Oligospermia,  62 
Operative  technic,  of  abdominal  incision, 

181 

author's  modification  of  Pfannen- 

stiel  incision,  182 

advantages  of,  184 

closure  of  incision,  188 

Kiistner-Rapin  incision,  182 


INDEX 


217 


Operative  technic,  Pfannenstiel  incision, 
182 

—  cervical  amputation,  178 

—  cervical  repair,  for  lacerations,  174 

—  curettage,   173 

—  dilatation  of  cervix,  169 

—  enlarging  of  external  os,  173 

—  enlarging  of  introitus  vaginalis,  169 

—  lengthening  of   uterovesical   ligament 

and  anterior  vaginal  wall,   179 

—  myomectomy,   194 

—  for  retrodisplacement  of  uterus,   190, 

191 

—  of  therapeutic  sterilization,  199 

—  for  tubal  occlusion,  197 
Origin  of  life,  fission,  17 

—  germ  cell,  microscopy  of,  18 

—  — ■  Schultze's  definition  of,  20 

—  Harvey's   aphorism,   16 

—  ovum,  18 

—  theories  of  preformation,    17 

—  Weismann's  theory  of  germ  plasm,  16 
Ova,    morphological    and    physiological 

differences      between      spermatozoa 

and,  29 
Ovarian   activity,   suspension   of,   causes 

of,  46 

causing  sterility,  46 

-due  to  disease,  46 

due  to  shock,  46 

Ovarian  sterility,  122 

— 'gross  and  histological   description  of 

non-ovulating  ovary,  122 

—  operative  treatment  of,  125 
Ovaries,  corpus  luteum  of,  21 

endocrine  function  of,  21 

internal  secretion  of,  21,  23 

large,    cystic,    associated   with    fre- 
quent and  profuse  menstruation,  23 

and  menstruation,  2^ 

of  pregnancy,  23 

—  endocrine   function  of,  21 

—  functions  of,  21 

—  gonorrheal  infection  of,  78 

—  histological  structures  of,  21 
. corpus  luteum,  21 

interstitial  cells,  21 

—  importance  of,  to  woman,  21 

—  internal  secretion  of,  21 

influence  of,  on  metabolism,  23 

—  position  of,  21 

—  sexual  value  of,  22 

—  tumors   of,    influence    on    sterility,   52 
Ovulation,  and  fertilization,  25 

—  in  lower  mammals,  26 

—  and  menstrual  cycle  in  woman,  25 

—  process  of,  24 


Ovulation,  protozoal  immortality,  24 

—  relationship      between      menstruation 

and,  46 

—  See  also  Reproduction,  methods  of 
Ovum,  18 

—  fertilization  of,  28 

—  imbedding  of,  ss 

Pain,     accompanying    menstruation,     in 

diagnosis  of  sterility,  65 
Parental  supervision,  decay  of,  12 
Pelvic  diaphragm,  description  of,  106 

—  muscles  of,  106 
levator  ani,  106 

Pelvis,  relative  position  between  uterus 

and,  102 
Peri-oophoritis,  78 
Pessary  treatment  of  retrodisplacements, 

function  of  pessary,  168 

—  technic,   163 

—  types  of  pessary,  166 
Pfannenstiel  incision,  182 

—  author's  modification  of,  technic,  182 
advantages  of,  184 

—  closure  of  incision,  188 
Pinhole  os,  case  reported,  87 

—  causing  temporary  sterility,  87 

—  treatment  of,  87 
Postcoital  tests  for  sterility,  68 
Postpartum  retrodisplacement  of  uterus, 

116 

—  pessary  treatment  of,  l6l 

—  treament  of,  119 
Postpartum   tubal   occlusion,    142 
Preformation  theory,  17 

Pregnancy,  after  operative  correction  of 
retrodisplacements,   117 

—  corpus  luteum  of,  23 

—  interrupted,  causes  of,  155 
relative  frequency  of,  155 

—  toxemias  of,  156 
Prematurity,  causes  of,  157 
— ^  gonorrhea,  158 

—  —  hemorrhage,  158 

—  occurrence  of,  159 

—  percentage  of,  158 

—  treatment  in  onset  of,   159 
Prostitution,  as  most  frequent  source  of 

venereal  infection,  75 

Protozoal  immortality,  24 

Protozoal   reproductivity,  28 

Psychical  impotence  in  the  male,  steril- 
ity due  to,  63 

Puerperal  atrophy  of  uterus,  case  cited, 
136 

—  definition  of,   136 

—  diagnosis  of,  136 


2l8 


INDEX 


Puerperal,  symptomatology  of,  136 

—  treatment  of,  137 

Race,  and  fertility,  39 

Rectal  examination  of  stout  subjects,  for 

sterility,  67 
Reproduction,     and     breeding     seasons, 

with  mammals,  36 

—  education  on  subject  of,  "32,  Ji 

—  essential  fact  of   (Wilson),  34 

—  growth  of  fertiHzed  cell,  33 
imbedding  of  ovum,  33 

—  and  heredity,  35 

—  methods  of,  28 

early  ideas  of  fertilization,  31 

formation  of  the  zyote,  29 

mitotic  cell  division,  30 

morphological     and     physiological 

differences  between  ova  and  sper- 
matozoa, 29 

protozoal  reproductivity,  28 

sexual  attraction,  31 

spermatozoal  life,  31 

union  of  cells,  32 

—  periodicity  of  menstruation,  37 

—  role  of  chorion  ferments  in,  50 

—  seasonal  influence  and  breeding,  37 

—  survival  of  fittest,  factors  making  for, 

35 

Punnett's  observations  on,  35 

Reproductive    period,    duration    of,    in 

men  and  women,  39 
Reproductivity,  and  the  educated  classes, 

3 

brain  development,  4 

careers,  4 

co-education,  4 

social  life,  5 

—  effect  on,  of  modern  civilization,  2,  3 

—  protozoal,  28 

Retrodisplacements    of    uterus,    accom- 
panying fibroids,  129 

—  anatomical  causes  leading  to,  112 

—  causing  sterility,  52 

—  classification  of,  no 

congenital  and  acquired,  113 

physiological  and  pathological,  iii 

—  correction    indicated    irrespective    of 

symptoms,   1 1 1 

—  determining  standard  of,  110 

—  determination  of,  112 
■ — factor  in  sterility,  113 

—  habitual  abortion  due  to,   115 

—  operative  treatment  for,  190 
technic,  191 

—  pessary  treatments  of,  161 
function  of  pessary,  168 


Retrodisplacements,  technic,  163 
types  of  pessary,  i66 

—  postpartum,  116 

pessary  treatments  of,  161 

treatment  of,  119 

—  pregnancy  after  operative   correction 

of,  117 

—  with  short  anterior  vaginal  wall,  in 

—  treatment  of,  choice  of,  117 

postpartum  cases,  119 

surgical,  118 

Retroflexion  of  uterus,  influence  of,  on 
sterility,  loi 

Schultze's  definition  of  germ  cell,  20 
Seasonal  influence,  and  breeding,  27 
Semen,  classification  of,  with  reference 
to  numerical  distribution  of  spermat- 
ozoa and  motility,  57 

—  constituents  of,   and  contributors   to, 

60 

—  See  also  Spermatozoa 

Sex,  creative  and  developmental  differ- 
ences of,  10 

Sex  hygiene,  education  in,  importance 
of,  73 

—  teaching  of,  8 

Sex  incompatibility,  as  cause  of  sterility, 

40 
Sexual  attraction,  between  germ  cells,  31 
Sexual  season,  ^7 

—  duration  of,  37 

—  in  male  ard  female  mammals,  37 

—  and  period  of  menstruation,  37 
Shock,    causing    suspension    of    ovarian 

activity,  46 
Skene's  glands,  gonorrheal  infection  of, 
84. 

—  cervical    and    vaginal,    to    determine 

presence  or  absence  of  spermatozoa, 
58 

—  number  and  position  of,  84 
Society,  modern,  effect  of,  on  reproduc- 
tivity, 2,  3,  4 

Spermatozoa,  description  of,  60 

—  destruction  of,  by  extremes  of  tem- 

perature, 60 

—  determination  of  presence  or  absence 

of,  by  vaginal  and  cervical  smears, 
.58 

—  influence    on,    of    alkaline    and    acid 

fluids,  60 

—  morphological   and  physiological   dif- 

ferences between  ova  and,  29 

—  motility  of,  57,  58 

—  number  of,  58 

in  single  ejaculation,  57 


INDEX 


219 


Spermatozoa,  quality  of,  58 

—  rate  o£  speed  of,  60 

—  time  of  leaving  testicle,  60 

—  vitality  of,  58 

—  —  retained  in  female  genital  tract,  60 

retained  in  frozen  semen,  60 

■  retained  in  incubator,  60 

—  —  tenacity  of,  60 
Spermatozoal  life,  31 

State,  obligations  of,  to  parents,  5 
Stenosis,  cervical,  treatment  of,  100 
Sterility,  acquired,  48 

—  among  native  born,  5 

—  associated  with  anteflexion  of  uterus, 

97 
with  cervical  stenosis,  lOO 

—  classification  of,  39 

absolute  and  relative,  40 

apparent  or  functional  and  poten- 
tial, 40 

congenital  and  acquired,  40 

primary  and  secondary,  40 

sex  incompatibility,  40 

—  conclusions  on,  209 

—  conditional,  93 

^  due  to  laceration  of  cervix,  93 

—  deciding  period  of,  in  married  life,  55 

—  definition  of,  39 

—  diagnosis  of,  determining  the  patency 

of  fallopian  tubes,  69 

history,  of  male  partner,  64 

imperfect  sexual  relations,  65 

leucorrheal  discharge,  65 

-menstruation,  65 

no  infallible  test  for,  72 

pain,  65 

by  physical  examination,  58 

postcoital  tests,  68 

rectal  examination  of  stout  sub- 
jects, 67 

study  and   examination,   of   female 

partner,  66 

of  male  partner,  64 

by  vaginal  and  cervical  smears,  58 

whether  in  male  or  female,  61 

—  in  educated  classes,  3 

—  etiology  of,  44 

absence     of     uterus,     ovaries,     or 

tubes,  44,  45 

absence  of  vagina,  44 

acquired  cases,  48 

age,  as   factor  in,  48 

marriage,  54 

alcohol,  vice  and  immorality,  55 

alcoholism,  parental,  53 

-anatomical  errors,  44 

anteflexion  of  uterus,  97 


Sterility,  etiology,  atresia  of  vagina,  44 

—  —  cervicitis,  chronic,  89 

—  —  —  and  laceration  of  cervix,  93 
climatic  conditions,  48 

constriction  of   vaginal,  44 

dietary,  46,  ^2) 

dyspareunia,  44,  65,  83 

endometritis,  50 

—  —  excessive  coitus,  48 

— -  —  fibroid  tumors  of  uterus,  50,  127 

functional,  53 

germ  cell  retardation,  43 

—  —  gonorrhea,  49,  53,  75 

and  tubal  occlusion,  138 

•  habitual  abortion,  95 

imperfect  sexual  relations,  65 

infantile  pelvic  organs,  45 

infantilism,  45 

inflammation  of  fallopian  tubes,  49 

—  —  inflammatory  diseases,  83 

inflammatory  processes,  53 

gonorrhea,  49,  53 

— •  —  kraurosis  vulva,  85 

laceration  of  cervix,  93 

and  chronic  cervicitis,  93,  94 

maldevelopment,  44 

nutrition,  46 

obesity,  47,  "]}) 

pathological  conditions,  43 

physical    and   mental    incompatibil- 
ity, 55 

pinhole  os,  87 

prevention  or  restriction  of  coitus, 

44 

retrodisplacements,  52,  113 

retroflexion  of  uterus,  loi 

stenosis  of  vagina,  44 

suspension   of   ovarian  activity,  46 

syphilis,  81 

tubal  occlusion,  138 

tumors  of  ovary,  52 

uterine  fibrosis,  51 

—  —  vaginismus,  zp4,  65,  82 
X-ray  exposures,  48 

—  fibroid,  126 

—  increase  of,  among  native  born,  5 
evils  responsible   for,  6 

—  influence  on,  of  age  in  marriage,  54 

—  in  the  male,  59 

determination  of,  61 

of  organic  impotence,  61,  62 

by  specimen    (Condom)   test,  61 

differentiated    from   non-impregna- 
tion, 62 

due  to  anorchism,  63 

due  to  aspermia,  62 

due  to  cryptorchidism,  63 


220 


INDEX 


Sterility,   in  the  male,   due  to   non-fer- 
tility of  spermatozoa,  6i 

due  to  organic  impotence,  6i,  62 

due  to  psychical  impotence,  63 

due   to   testicular   absence   or   dis- 
ease, 62 

due  to  X-ray  exposure,  64 

importance  of  determining,  61,  64 

impotentia  coeundi,  61 

impotentia  generandi,  61 

percentage  of,  61 

—  male  and  female,  relative  proportion 

of,  41 

—  in  middle  classes,  7 

—  ovarian,  122 

gross    and   histological    description 

of  non-ovulating  ovary,  122 
operative  treatment  of,  125 

—  pathological  conditions  influencing,  43 

—  predisposing  factors  in,  41 

—  primitive  woman's  freedom  from,  43 

—  and  prostitution,  75 

—  relative,  and  habitual  abortion,  95 

—  retrodisplacements  of  uterus  a  factor 

in,  113 

—  temporary,  46 

—  treatment  of,  in  anteflexion  of  uterus, 

59 

consideration  of,  72 

in  enlargement  of  adnexa,  59 

hygienic  measure,  y^ 

in  infantile  uterus,  58 

in  laceration  of  cervix,  59 

operative.     See  Operative  Technic 

in  retroflexion  of  uterus,  59 

in  subinvolution  of  uterus,  59 

in  tumors  of  uterus,  59 

in  uterine  displacements,  59 

—  and    uterine    displacements,    anteflex- 

ion, 59 
retroflexion,  59 

—  and  "woman's  sphere,"  4,  9,  11 
influence    on,    of    civilization    and 

legislation,  11 

—  See  also.  Marital  Unfruitfulness 

Unfruitful  Marriages 

Sterilization,  therapeutic,  author's  tubal 

closure,  202 

indications  for,  200 

methods  employed,  199 

and  therapeutic  abortion,  combined, 

indications  for,  204 

cases  illustrating,  206 

technic  of,  204 

author's  208 

tubal  resection,  201 

Subinvolution  of  uterus,  case  cited,  135 


Subinvolution  of  uterus,  causal  factors 
in,  134 

—  characteristics  of,  134 

—  curettage  indicated  in,  59 

—  definition  of,  134 

—  symptomatology  of,  134 

—  treatment  of,  135 

Superinvolution  of  uterus.  See  Puer- 
peral Atrophy  of 

S.vphilis,  as  cause  of  abortion,  premature 
birth  and  fetal  and  infant  mortality, 
49 

—  percentage  of  male  and  female  pop- 

ulation affected,  49 

—  statistics  on,  49 

—  treatment,     anti-syphilitic,     of     pros- 

pective mothers,  50,  81 

Testicular   absence    or    disease,    causing 

sterility,  62 
Therapeutic    abortion,     indications     for, 

199 

—  and     sterilization     combined,     indica- 

tions for,  204 

cases  illustrating,  206 

technic  of,  204 

author's,  208 

Therapeutic  sterilization,   author's  tubal 

closure,  202 

—  indications  for,  200 

—  methods  employed,  199 

—  tubal  resection,  201 
Toxemias  of  pregnancy,  156 

Tubal  occlusion,  of  doubtful  etiology, 
case  cited,  143 

—  due  to  acute  infections,  142 
cases  cited,  142,  143,  144,  145 

—  —  postpartum,  142 

—  due  to  gonorrhea,  138 
cases  cited,  140,  141 

—  etiology  of,  138 

—  operation  for,  196 
technic  of,  197 

—  role  of,  in  sterility,  138 

—  route  of  infection  in,  138 

Tubal  resection,  as  method  of  thera- 
peutic sterilization,  201 

Tumors,  malignant,  of  uterus,  a  barrier 
to  conception,  52 

—  of  ovary,  influence  of,  on  sterility,  52 

—  of  uterus,  removal  of,  59 

Unfruitful    marriages,    factors    contrib- 
uting to,  57 
Urethra,  gonorrheal  infection  of,  77 
Urethral  caruncles,  causing  painful  co- 
itus, 85 

—  treatment  of,  85 


INDEX 


221 


Uterine  fibrosis,  as  factor  in  diminished 
fertility,  51 

Uterovesical  ligament  and  anterior  va- 
ginal wall,  lengthening  of,  179 

Uterus,  anatomy  of,  loi 

—  anteflexion     of,     abortion     generally 

succeeding  pregnancy  in,  97 

associated  with  sterility,  97 

degrees  of,  97 

examination    and    treatment   under 

anesthesia,  99 

mutilating  operations  for,  98 

second  pregnancy  often  successful 

in,  98 

—  —  significance  of,  97 
and  sterility,  59 

treatment  of,  under  anesthesia,  99 

by  faulty  surgery,  100 

proper  development  of  uterus,  98 

—  attachments  of,  108 

—  bulk  and  weight  of,  lOl 

—  dependence  of,  for  support,  on  neigh- 

boring viscera,  108 

—  displacements  of,  as  influencing  steril- 

ity, anteflexion,  59 
retroflexion,  59 

—  fibroids  of,  and  accompanying  retro- 

displacements,  129 

affecting   fertility  and   sterility,   50 

age  as  factor  in,  126 

case  cited,  as  noteworthy  exception 

to  rule,  130 
conception    following    removal    of, 

126 

-diagnostic  errors  in,  129 

frequency  of,  51 

menstruation  in,  130 

multiple,  129 

— ■  —  myomectomy  for,  132 

technic  of,  194 

occurrence  of,  126 

as  result  of  sterility,  50 

—  gonorrheal  infection  of,  78 
— -gravity  and  position  of,  109 

—  infantile,  treatment  of,  to  cure  steril- 
,  ity,  58 

—  investing  peritoneum  of,  108 

—  involution  of,  process  of,  134 

—  ligament  attachments  of,  103 
broad  ligaments,  104 

cervico-vaginal  insertion  with  fas- 
cial attachment  to  bladder,  103,  105 

—  —  round  ligaments,  105 

'transverse  cervical,  105 

utero-sacral  ligaments,  104 

—  malignant  tumors  of,  barrier  to  con- 

ception, 52 


Uterus,  and  pelvic  diaphragm,  106 

—  position  and  gravity  of,  109 

— ^  puerperal  atrophy  of,  case  cited,   136 

definition  of,  136 

diagnosis  of,  136 

symptomatology  of,  136 

treatment  for,  137 

—  relative  position  between  pelvis  and, 

102 

—  retrodisplacements    of,    accompanying 

fibroids,  129 
— •  —  anatomical   causes   leading   to,    112 

—  —  causing  sterility,  52 
classification  of,  no 

—  —  congenital  and  acquired,  113 
correction  indicated  irrespective  of 

symptoms,  in 

determination  of,  112 

determining  standard  of,  no 

factor  in  sterility,  113 

habitual  abortion  due  to,  115 

operative  treatment  for,  190 

technic  of,  191 

pessary  treatments  of,  161 

function  of  pessary,  168 

technic,  163 

types  of  pessary,  166 

physiological  and  pathological,   in 

postpartum,  116 

pessary  treatments  of,  161 

treatment  of,  119 

—  — ^  pregnancy   after    operative   correc- 

tion of,  117 
with    short    anterior   vaginal    wall, 

in 

treatment  of,  choice  of,  117 

for  postpartum  cases,  119 

surgical,  118 

—  retroflexion  of,  and  sterility,  59 

—  subinvolution  of,  case  cited,  135 
causal  factors  in,  134 

characteristics  of,  134 

curettage  for,  59 

definition  of,  134 

symptomatology  of,  134 

treatment  of,  135 

—  superinvolution    of.      See    Puerperal 

Atrophy  of 

—  support  of,   in   ligament  attachments, 

103,  104,  105 

—  suspensory  structures  of,  103,  104,  105, 

107 


Vagina,  absence  of,  as  cause  of  sterility, 

-14 
—  atresia  of,  as  cause  of  sterility,  44 


222 


INDEX 


Vagina,  construction  of,  hindering  inter- 
course, 44 

—  gonorrheal  infection  of,  ^^ 

—  stenosis  of,  preventing  intercourse,  44 
Vaginal  cysts,  causing  dyspareunia,  85 

—  treatment  of,  85 
Vaginal  incision,  181 

Vaginal  smears,  to  determine  presence 
or  absence  of  spermatozoa,  58 

Vaginal  wall,  anterior,  and  uterovesical 
ligament,  lengthening  of,  179 

Vaginismus,  causing  sterility,  65 

—  enlarging  the  introitus  vaginalis  for, 

technic  of  operation,  169 

—  preventing  coitus,  44 

—  treatment  of,  alcoholic  beverages,  82 
operative,  83,   169 

physical,  82 

psychical,  82 

Venereal  infection,  in  causation  of 
sterility,  75 

—  gonorrhea.    See  Gonorrhea 
Virility    in    the    male,    beginning    and 

duration  of,  60 


Vulva,  gonorrheal  infection  of,  ^^ 
Vulvo-vaginal  abscess,  treatment  of,  84 

Weismann's  theory  of   germ   plasm,    16 
Woman,  brain  development  in,  4 

—  and  careers,  4 

—  and  co-education,  4 

—  and  education,  3 

—  freedom  of,   from   sterility,  in  prim- 

itive state,  43 

—  and  idealization  of  motherhood,  12 

—  importance  to,  of  ovaries,  21 

—  and  social  life,  5 
"Woman's  sphere,"  4,  9,  11 

—  influence  on,  of  civilization  and  legis- 

lation, II 

X-ray,  influence  of,  on  sterility,  in  male, 

64 
X-ray  exposures,  sterilizing  effect  of.  48 

Zyote,  formation  of,  29 


(2) 


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